New Patient Registration and Questionnaire Form 2024

Fields marked "REQUIRED" are compulsory. You should only send this form if you are sure that you are eligible to join this practice. You can check on our website to see if you are in our catchment area . 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. We do need proof of address and ID before we can register you with us. Please send these to churchfields.surgery@nhs.net this is a secure NHS email. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 30/04/2024

Patients Details

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

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

If you are returning from the armed forces

Address before enlisting

Service/Personnel No.

Enlistment date

SUPPLEMENTARY QUESTIONS | 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 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. 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 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 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.

Are you a parent or guardian, filling out this form on behalf of a child under 16?

Name parent or guardian

Relationship to patient:

Signed

Date

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK. 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 the GP practice, including at hospital).

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

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.

Questionnaire

Here you will be asked medical related questions. Please fill in as much detail as you can. This section will include medical Information, smoking history, alcohol history, family history and next of kin details.

Women

Have you ever had a cervical smear?

Yes No

If 'yes', please state when, where and the result

Smoking

Do you smoke?

Yes No

If 'No', have you ever smoked?

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week?

Alcohol

MEN: How often do you have EIGHT or more drinks on one occasion?

WOMEN: How often do you have SIX or more drinks on one occasion?

How often during the last year have you failed to do what was normally expected of you because of drinking?

Family History

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer.

Carers

Do you have a carer? *

Yes No

If yes please give details

Are you a carer? *

Yes No

If yes please give details

Next of Kin

Please give name, address, telephone number and relationship of next of kin

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

Have you had a flu vaccination? Enter date or 'never':

Have you had a pneumococcal vaccination? Enter date or 'never'

Contacting You

Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders.

Yes No

Summary Care Record Consent

If you are registered with a GP practice in England, you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past. Information about your healthcare may not be routinely shared across different healthcare organisations and systems. You may need to be treated by health and care professionals who do not know your medical history. Essential details about your healthcare can be difficult to remember, particularly when you are unwell or have complex care needs. Having a Summary Care Record can help by providing healthcare staff treating you with vital information from your health record. This will help the staff involved in your care make better and safer decisions about how best to treat you. For more information, please visit https://www.digital.nhs.uk/summary-carerecords/patients, call NHS Digital on 0300 303 5678 or speak to your GP Practice.

You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care. Your options are outlined below; *

Express consent for medication, allergies and adverse reactions only

 Express consent for medication, allergies, adverse reactions and additional information

 Express dissent for Summary Care Record (opt out)

Signature

Signature

Date

If you are over 16, you need to send us photo ID (driving license, passport) AND proof of address (utility bill, bank statement)? Please either send these to churchfields.surgery@nhs.net or bring them into reception. You MUST do this or your registration will not be accepted. We will dispose of the registration after 2 weeks if we haven't received it. *

Yes I will now

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New Patient Registration and Questionnaire Form 2024

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