New Patient Registration - Out of Area

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We consider applications from patients living outside of the practice boundary providing certain criteria is met and that it is clinically suitable.

 
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Patient's Details

Information we need to register you with the practice
Please note all fields marked with a * are mandatory for your registration

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Ethnicity & Religion
Emergency Contact
Previous Details
Please include postcode
If you are from abroad
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If you are returning from abroad

Previously been registered with the NHS in the UK

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Were you ever registered with an Armed Forces GP
This includes even 1 day service, regular or reservist and includes the Merchant Navy

Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services

Supplementary Questions

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 at reception. Alternatively for more information go to the NHS Website

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.

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.

European Economic Area (EEA) Country

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.

Please enter the details from your EHIC or PRC below.

S1 Form

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
 
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Lifestyle
Your Personal Alcohol Consumption

What does 1 unit of alcohol look like?

Audit Score Result

you have a score of 

If you are drinking less than 14 units of alcohol per week, then your drinking is within the UK Chief Medical Officers' low risk drinking guidelines.

But if you are drinking regularly at or above the low risk guidelines of 14 units a week, or, you are drinking six or more units - if you are female - or eight or more units - if you are male - in one single session (binge drinking), please consider the increased serious risks to your health being caused by your current drinking pattern.

 
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Adult Females
Please use this date format: DD/MM/YYYY.
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Immunisation History
Please include dates.
Medical History
Please include dates.
Please include dates.
Please include dates.

Over 75 years old?

The Department of Health has advised that all patients of 75years and older have a named and accountable GP to oversee their care. Please ask the name of the GP assigned to oversee your care. Please note this does not prevent you from seeing the GP of your choice.

Allergies
 
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Summary Care Record

Summary Care Record (SCR)

The Summary Care Record (SCR) system is designed to help both your GP and any emergency staff you contact when the surgery is closed to treat your health needs more efficiently.

Your information will be shared between your GP practice, our local hospital and Out Of Hours service. This will enable your GP surgery to access results and any visits you have at the hospital quickly and efficiently, but it also means that if you have an emergency and contact the Out Of Hours service or visit A&E they will have access to your current medications as well as allergies and are better able to treat you.

If you do not return this form, a Summary Care Record will be created for you based on implied consent

 
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Identification Upload

Patient Identification

To fully register you at the practice, we need Two forms of Acceptable ID (if not possible, please let us know).

We will not store these documents and we will securely delete / destroy them after our initial verification.

OPTIONAL: Photo of your face to add to your records to help us identify you (if you agree)

Acceptable Identification: Photo Driving License, Passport, Tenancy agreement, Mortgage statement, Bank statement, Utility bill (date within the past 3 months) etc.

Application for online access

You can now book appointments, order repeat prescriptions and see some of the information in your GP records, including medications and allergies online.
The surgery has a responsibility to look after your GP records. You must also take care online and make sure your personal information is not seen by anyone who should not see it.

Keeping your username and password safe

When you register to use Online Services, you will create your own username and password, which you will use to log in. You should not share your log in details with others.
To protect your information from other people:

  • You should keep your password secret and it is best not to write it down. If you must write it down, keep a reminder of the password, not the password itself. This should be kept in a secure place.
  • If you think someone has seen your password, you should change it as soon as possible. You may want to call the surgery if you are not able to change it right away, for example, when you do not have access to the internet.
  • You should not share your user name or password. No one should force you to show them your log in details, you have the right to say no. If someone forces you, tell the surgery as soon as possible.
 

Using a shared computer

You need to take extra care when using a shared computer to look at your records online. This could be at the library, at work, at university or at home. To protect your personal information from others  when using a shared computer. 
You should:

  • Look around to see if other people can see what is on the computer screen. Remember, your records contain your personal information.Look around
  • Keep your username and password secret. Just like your bank account PIN you would not want others to know how to get into your records.
  • Make sure you log out when you finish looking at your records so that no one else can see your personal information or change your password without your knowledge.
 

Incorrect information in your records

On rare occasions information in your records might be incorrect.

  • If you find any incorrect information you should let the surgery know as soon as possible.
  • If you see information about anyone else in your records, log out immediately and let the surgery know as soon as possible.

Patients under the age of 16 cannot have their own account
Patients over the age of 16 must have their own personal email account which cannot be shared

 
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NHS Organ Donor registration

More information on Organ Donation

NHS Blood Donor registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website or call direct on 03001232323

What happens to my information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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