RPC New Patient Registration Form

Fields marked "REQUIRED" are compulsory. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Your details will be held at the surgery for a limited period of time. You are required to present in person to sign your registration form and provide proof of your address. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 09/03/2023

Patient's Details

Which surgeries do you wish to register with? *

Grangewood, Inkersall and Rectory Road

Ashgate Manor, Holme Hall and Whittington

Title

Surname *

First name(s) *

Previous Surname

Date of Birth *

NHS number

Birth Town *

Birth Country *

Sex

Male

Female

Address *

Postcode *

Telephone *

Please help us trace your previous medical records by providing the following information

Your previous address in UK

Name of previous GP while at previous address

Address of that Doctor

If you are from abroad

Your first UK address where registered with a GP

If previously resident in UK, date of leaving

Date you first came to live in UK

Non-UK EHIC or PRC

Please complete this section if you live in another EAA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EAA member state. Do not complete this section if you have an EHIC issued by work. By using your EHIC 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 with the cost recovery process. Your EHIC PRC or S1 information will be shared with the The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

Do you have a non-UK EHIC or PRC?

Yes No

If yes, please enter details from your EHIC or PRC below

Country Code

Name

Given Names

Date of Birth

Personal Identification Number

Identification number of the institution

Identification number of the card

Expiry Date

PRC validity period

a) From

b) To

Please tick if you have an S1 (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.

I have an S1 form

Declaration

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.

Patient declaration for all patients who are not ordinarily resident in the UK

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 resiliently 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 test of suspected infectious diseases and any treatment of those disease are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges. 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 the 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 tick one of the following boxes

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

I understand I have valid exemption from payment of the immigration Health Charge, when accompanied by a valid visa. I can provide documents to support this when requested

I do not know my chargeable status

Were you ever registered with an Armed Forces GP

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas:

Regular

Reservist

Veteran

Family Member (Spouse, Civil Partner, Service Child)

Discharge Date (If Applicable)

Address before enlisting

Service/Personnel No.

Enlistment date

Contact Preferences

Relations

Name of Next of Kin

Next of Kin's Date of Birth

Relationship to you

Next of Kin's Contact number

Next of Kin's Address

Are you a carer?

If no, please skip to the following section

Are you a carer?

Yes No

Is the person you care for registered at our surgery? (If yes please answer the follow questions, if no please skip the next section)

Yes No

Name of person you care for

Date of Birth

Relationship to you

Contact number

Address

Do you have a carer?

If no, please skip to the following section

Do you have a carer?

Yes No

Name of Carer

Date of Birth

Relationship to you

If you are registering a child under 18 years old, please read and complete the section below

Organisation name of Nursery/School/Children's centre

ORGANISATION ADDRESS OF NURSERY/SCHOOL/CHILDREN'S CENTRE

ORGANISATION CONTACT NUMBER OF NURSERY/SCHOOL/CHILDREN'S CENTRE

Parental Responsibility - Please give details below of who has Parental Responsibility for the child being registered:

Consent for treatment can only be given by the person/s with parental responsibility** for the child receiving the treatment ** Biological mothers always have parental responsibility for their child (unless rights have been removed by a court order). All other parents/guardians can acquire parental responsibility in various ways: - Where the parents are married at the time of the birth the father will automatically have parental responsibility - In the case of the child being born after 1 December 2003, where the fathers details are registered on the birth certificate the father will also have parental responsibility even if parents are unmarried. - If the parents are unmarried at the time of birth and the father is not named on the birth certificate a father does not have parental responsibility unless a formal agreement with the mother has been acquired, by order of the Court or by obtaining a residence order (which governs where a child is to live) in relation to the child. With a parent's consent others (e.g. partner, other relatives etc) can obtain parental responsibility in relation to the child either by entering into a parental responsibility agreement, or on application to the court. Parental responsibility gained in this way will not be lost unless rights have been removed by a court order. Parental responsibility is also obtained through the making of a residence order (an order made under the Children Act 1989), and through the act of adoption.

(1) Name

(1) Date of Birth

(1) Relationship to Child

(1) Contact Number

(1) Address

(2) Name

(2) Date of Birth

(2) Relationship to Child

(2) Contact Number

(2) Address

New Patient Questionnaire

Ethnicity *

Asian or Asian British

Black or Black British

Mixed other background

White British

Other

White Irish

Prefer not to say

Please state your main spoken language *

Do you require an interpreter *

Yes No

Your General Health

Record Sharing Opt-out Form

Care Data - Do you consent to your personal information (NHS no. and postcode) being upload to HSCIC (Health and Social Care Information Centre) Information such as your postcode and NHS number, but not your name, will be used to link your records in a secure system, so your identity is protected. Information which does not reveal your identity can then be used by others, such as researchers and those planning health services, to make sure we provide the best care possible for everyone. How your information is used and shared is controlled by law and strict rules are in place to protect your privact *

Yes No

Summary Care Record - A summary care record is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had stored in a central location. Having this information stored in one place makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed. Please be assured that this information can only be accessed from secure NHS networks by NHS professionals with specific permissions on their personal chip and pin cards. Would you like the following extra clinical information to be viewable on your Summary Care Record; Significant problems and procedures (past and present), Communication preferences, End of life care information (where applicable) and Immunisations? *

Yes No

Confirmation

I hereby certify that the above statements are true and correct to the best of my knowledge. *

Yes No

Signed *

Date *

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