Fields marked "REQUIRED" are compulsory. You should only send this form if you are sure that you are eligible to join this practice. 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: 25/07/2022
New Patient Health Questionnaire
Welcome to the Practice.
We would be grateful if you could take the time to complete this registration questionnaire.
Please note the following:
· Please read the questions overleaf and complete as fully as possible.
· If you are on regular medication, you will need to make an appointment with a doctor before a repeat prescription can be issued.
· If you have any outstanding hospital appointments please contact the hospital and advise them that you have changed your doctor and your name and address (if applicable).
Alcohol - answer only if 15 years old and over
For the following questions, please circle the answer which best applies:
1 drink = ½ pint of beer or 1 glass of wine or 1 single spirit
Smoking - answer only if 15 years old and over
Smoking can have a significant impact on your health. If you would like help to stop smoking, free smoking cessation services are available through local pharmacies.
Please help us trace your previous medical records by providing the following information
If you are from abroad
Were you ever registered with an Armed Forces GP
These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.
*Not all doctors are authorised to dispense medicines
What is your ethnic group?
Please tick one box that best describes your ethnic group or background from the options below:
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
How will your EHIC/PRC/S1 data be used?