New Patient Registration Form (GMS1) V3

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. Once you have completed your form, please email ID documents to bhccg.clinicalstpeters@nhs.net. To become registered at St Peter’s Medical Centre please can you complete this Registration Form and produce proof of identification with name and current address. • Photographic ID e.g. passport, driving licence, bus pass AND • Proof of address in the form of an up to date utility bill, bank statement, Tenancy Agreement or Solicitors letter (dated within the last 3 months) • Birth Certificate (For registering children) If you are unable to provide any of the above documents, then please speak with a member of the reception team. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 02/10/2020

Patients Details














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




If you are from abroad




If you are returning from the armed forces




Complete Registration






NHS Organ Donor Registration

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. For more information, please ask for the leaflet on joining the NHS Organ Donor Register. From Spring 2020 you will be automatically registered to be an organ donor unless you opt out. For more information, please visit: www.organdonation.nhs.uk/register-to-donate




NHS Blood Donor Registration

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






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.







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).















Carer Details

If you have a carer, we will need consent from the person before we can record their details on your health records – please provide a signed letter from them including name, DOB, address and contact number.









Current Medication

If you are taking a repeat medication you will need to speak to a member of our pharmacy team




Past Medical History

Please complete any past medical history




Family History

Please tick if any close blood relatives have any of the following health problems/diseases.



Women







Blood pressure / height / weight / smoking status









Exercise


Consent for TEXT communication


Consent for EMAIL communication

We will send you an automatic verification request via email – please follow instructions carefully by clicking link we send. You will need to answer some security questions. We cannot verify email manually.



Summary Care Record (SCR)

NHS England is using an electronic record called the Summary Care Record to support patient care. Allowing authorised health care staff to have access to this record will improve decision making by doctors and other health care professionals and has prevented mistakes being made when patients are being cared for in an emergency or when their GP practice is closed. Your Summary Care Record contains important information about any medication you are taking, any allergies you suffer from and any bad reactions to medicines that you have previously experienced. Your Summary Care Record also includes your name, address, date of birth and your unique NHS number to help identify you correctly. For further information, visit: https://digital.nhs.uk/services/summary-care-records-scr/summary-care-records-scr-information-for-patients


Ethnicity


Spoken Language

Main spoken/written language





Sexual Orientation


Religion/Belief


Disabilities



Alcohol

Alcohol use can affect your health and can interfere with certain medications and treatments. Your answers will remain confidential so please be honest.

















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.

Your Data Matter to the NHS:

Information about your health and care helps us to improve your individual care, speed up diagnosis, plan your local services and research new treatments. In May 2018, the strict rules about how this data can and cannot be used were strengthened. The NHS is committed to keeping patient information safe and always being clear about how it is used. You can choose whether your confidential patient information is used for research and planning. TO FIND OUT MORE VISIT NHS.UK/YOUR-NHS-DATA-MATTERS

Thank you for completing your registration form.

Please now email your ID documents to bhccg.clinicalstpeters@nhs.net. We are unable to complete your registration until we receive this information. Thank you.