-New Patient Registration Form (GMS1) V2

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: 21/01/2022

  • Patients Details

    Sex
    Date of Birth
    For example, 15 3 1984
    Ethnic Group
    Do you need an interpreter?
    If yes, please select from Below (optional)
  • Please help us trace your previous medical records by providing the following

  • If you are from abroad

    If previously resident in UK, date of leaving (optional)
    For example, 15 3 1984
    Date you first came to live in UK (optional)
    For example, 15 3 1984
  • If you are returning from the armed forces

    Enlistment date (optional)
    For example, 15 3 1984
  • Medical Information

    Have you suffered from? (select as appropriate) (optional)
    Are you registered disabled
    Are you allergic to any medicines?
    Have you ever refused treatment/screening of any kind?
    Do you have any other mental health issues?
  • Smoking

    Do you smoke
    If no, have you ever smoked?
  • Alcohol

  • Women

    Have you ever had a cervical smear?
  • Carers

    Do you have a carer?
    Are you a carer?
  • Family History

  • Next of KIN

  • Complete Registration

    If you are registering a child under 5 (optional)
    If you need your doctor to dispense medicines and appliances (optional)
    Signature
  • 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 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.
  • 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
  • Signature

    Date
    For example, 15 3 1984
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