2024 New Patient Registration Form (GMS1)

ANY SECTION UNFILLED WILL RESULT IN LATE REGISTRATION OR REGISTRATION MAY BE REJECTED. IF THEY ARE UNABLE TO FILL ONLINE FORM OR SUBMIT MANDATORY INFORMATION THEN THEY HAVE TO ATTEND THE SURGERY IN PERSON FOR REGISTRATION.

Last Updated: 21/02/2024

Patient's Details

Title *

Surname *

First name(s) *

Previous Surname *

Birth Town *

Birth Country *

Date of Birth *

NHS number

Sex

Male

Female

Unspecified or not known

Address *

Postcode *

Telephone *

Email address *

I am a student at:

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/ Surgery *

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

Complete Registration

If you are registering a child under 5

I wish the child above to be registered with the named doctor for Child Health Surveillance

If you need your doctor to dispense medicines and appliances *

I live more than 1 mile in a straight line from the nearest chemist

I would have serious difficulty in getting them from a chemist

Not applicable

Date

NHS Organ Donor Registration

For more information, please ask for the leaflet on joining the NHS Organ Donor Register

NHS Blood Donor Registration

For more information, please ask for the leaflet on joining the NHS Blood Donor Register

Would you like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood? *

I consent to join the NHS Blood Donor Register

I do NOT consent to join the NHS Blood Donor Register

Signature confirming consent to inclusion on the NHS Blood Donor Register *

Date *

Have you given blood in the last 3 years? *

Yes

Not applicable

Preferred address for donation: (if different from above, e.g. place of work)

Postcode

Additional information

Do you want important information from your GP record to be available to other health and care professionals?

Your GP surgery needs permission to share important information from your GP record. This is called a Summary Care Record (SCR). Your SCR can only be shared with health and care staff across England who are providing you with direct care. It gives them access to vital information from your GP record.

Do you want important information from your GP record to be available to other health and care professionals? *

Yes, share a Summary Care Record with additional information Includes details of your medicines, allergies, adverse reactions and additional information, which includes details of any significant illnesses and health problems, operations and vaccinations

Yes, share a Summary Care Record without additional information Includes details of your medicines, allergies and adverse reactions only

No, do not share a Summary Care Record Details of your medicines, allergies,

Information on eligibility to free care outside the GP practice

Anyone can register with a GP practice and receive free medical care from that practice. However, should you be referred for treatment outside the practice or need unplanned care, for example at a hospital, charges may apply if you are a visitor or temporary resident.

Some groups of visitors or temporary residents are eligible to receive this care free of charge. Documentation may be required to demonstrate eligibility.

Examples of those eligible include:

•

refugees, asylum seekers, those receiving certain forms of state support

•

suspected or confirmed victims of modern slavery and human trafficking

•

temporary residents with a valid visa of over 6 months. You may have paid the immigration health surcharge with your visa application. Note that assisted conception services remain chargeable to this group

•

visitors from the EEA will need to provide their EHIC (European Health Insurance Card), which covers immediately necessary unplanned treatment, or a S2 form which covers planned treatment.

Additionally, some services are free of charge to all visitors, including diagnosis and treatment for infectious diseases and sexually transmitted infections.

Immediate necessary care, maternity care and other urgent care that cannot wait until a chargeable visitor’s departure from the UK will not be withheld or delayed due to charges. But non-urgent treatment will not be given until full payment is received.

More information can be found in the patient leaflet available from the GP practice.

Select the statement that applies to you *

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

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

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.

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.

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2024 New Patient Registration Form (GMS1)

Further Information