New Patient Registration

If you would like to register with the practice, please use this form.

Please be aware that patients should avoid attending in person to sign forms.

We accept registrations outside of our practice boundary. Please check your address against our practice boundary. If you are living outside the boundary, please indicate this on the registration form.

New Patient Registration - Stonecot
New Patient Registration - Stonecot

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Practice Boundary

Do you live inside our practice boundary? *

Yes

No

We accept registrations outside of our practice boundary however you will no longer be entitled to home visits from the practice and would need to contact 111 for help and advice should the need to be visited at home arise in the future. Please consider this carefully as in the event of you becoming dependant on community services e.g. District Nursing, Health Visiting or Midwifery services at any time in the future, as you will need to access them from your place of residence. In these circumstances you would be required to register with a local GP to be able to access your local services.

*

I understand the terms in regards to registering when I live outside of the practice boundary

Patient's Details

Title *

Mr

Mrs

Miss

Ms

Other

Please specify:

Surname: *

Previous Surnames:
If you do not provide this, it will be more difficult to trace your records.

First Name(s) *

Date of Birth: *
Please use this date format: DD/MM/YYYY.

Gender *

Male

Female

Indeterminate

NHS Number:

Town and Country of birth: *

Home Address: *

Postcode: *

Email Address: *
Any responses we send will go to this email address.

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

Can we contact you by text?

Yes

No

Can we contact you by email?

Yes

No

Ethnicity

Please specify the ethnic group you consider you belong to:

White British

White Irish

Black Caribbean

Black African

Black Caribbean and White

Black African and White

Indian

Pakistani

Bangladeshi

I do not wish to state

Other ethnic group

Please state:

Do you speak English?

Yes

No

Do you read English?

Yes

No

First Language:

Emergency Contact

Full Name:

Relationship to you:

Phone Number:

Home Address:

Are they your next of kin?

Yes

No

If you give permission for your next of kin to be able to discuss your medical records then please do put this in writing with a signature and submit to the practice separately.

Do you give us permission to discuss your medical records with them?

Yes

No

Allergies

Do you have any allergies?

Yes

No

Please specify what you are allergic to, what happens and when you had your first reaction:

Previous Details

Previous address in UK (if any): *
Please include postcode. If you do not have a previous address, please state N/A. If you do not provide this, it will be more difficult to trace your records.

Name and address of previous GP (if any): *
Please include postcode. If you do not have a previous address, please state N/A. If you do not provide this, it will be more difficult to trace your records.

If you are from abroad

Registering with the NHS for the first time in the UK

Are you from outside the UK? *

Yes

No

Date you came to live in the UK: *
Please use this date format: DD/MM/YYYY.

If you are returning from abroad

Previously been registered with the NHS in the UK

Date you left the UK:
Please use this date format: DD/MM/YYYY.

Date you returned to the UK:
Please use this date format: DD/MM/YYYY.

Supplementary Questions

I am not ordinarily a resident in the UK

I am not ordinarily a resident in the UK

Ordinarily Resident

Anybody in England can register with a GP practice and receive free medical care from that practice.

However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK.

Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.

More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice. Alternatively for more information go to www.nhs.uk/visitingengland.

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.

The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

Please select one of the following statements:

I understand that I may need to pay for NHS treatment outside of the GP practice

I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge (“the Surcharge”), when accompanied by a valid visa. I can provide documents to support this when requested

I do not know my chargeable status

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate
action may be taken against me.

A parent/guardian should complete the form on behalf of a child under 16.

Signature:

Print Name:

On behalf of:

Relationship to patient:

Date:

European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea

Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?

Yes

No

Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?

Yes

No

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

EHIC/PRC

Please enter the details from your EHIC or PRC below.

Country Code:

3. Name:

4. Given Names:

5. Date of Birth:

6. Personal Identification Number:

7. Identification number of the institution:

8. Identification number of the card:

9. Expiry Date:

PRC validity period - from:

PRC validity period - to:

S1 Form

Do you have an S1 Form?

I have an S1 form (e.g. you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state).

Please give your S1 form to the practice staff.

How will your EHIC/PRC/S1 data be used?

By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process.

Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

Carers

Do you have a carer?

Yes

No

Are you a carer for someone?

Yes

No

Name of carer:

Phone Number:

Address:

If you give permission for your carer to be able to discuss your medical records then please do put this in writing with a signature and submit to the practice separately.

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New Patient Registration - Stonecot

Practice Boundary

Patient's Details

Ethnicity

Emergency Contact

Allergies

Previous Details

If you are from abroad

If you are returning from abroad

Supplementary Questions

Ordinarily Resident

European Economic Area (EEA) Country

EHIC/PRC

S1 Form

How will your EHIC/PRC/S1 data be used?

Carers

Hay Fever