New Patient Registration Form (GMS1) + Health questionnaire

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: 22/08/2023

Patient's Details

Title *

Surname *

First name(s) *

Previous Surname *

Birth Town *

Birth Country *

Date of Birth *

NHS number *

Sex *

Male

Female

Address *

Postcode *

Telephone *

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 not applicable put N/A *

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

Signature *

Signature of patient

Signature on behalf of patient

Signed

Date

NHS Organ Donor Registration

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

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

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

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

GP SECTION

GP SIGNATURE

DATE

Supplementary questions

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.

NEW PATIENT HEALTH QUESTIONNAIRE

This section is used to capture data for all new patients registering with the practice. This will help us gather essential information about your current and previous medical history.

This section must be completed to allow registration to proceed.

Full name *

Land line number *

Mobile number *

Email address *

Occupation *

Weight (approx) *

Height *

Next of Kin details

Full Name *

Relationship to you *

Full address inc postcode *

Contact number *

HEALTH HISTORY

MEDICATION

Are you on any regular medication? If so please list below or type none *

When is your repeat medication next due?

Pharmacy - We send all prescriptions electronically to your chosen pharmacy. Please choose from the following *

If you have any allergies to medication please list them below or type NONE *

SMOKING HISTORY

Do you smoke? *

Yes No

If yes, how many cigarettes or ounces of tobacco do you smoke per day?

Total time you have been a smoker

Would you like advice on how to stop smoking?

Yes No

EX - SMOKER?

When did you stop smoking?

Total time you where a smoker

How much did you used to smoke?

Do you use e-cigarettes?

Yes No

ALCOHOL CONSUMPTION

How often do you have a drink containing alcohol?

How many units of alcohol do you drink on a typical day when you are drinking? *

How often did you have 6 or more units if female , or 8 units if male, on a single occasion in the last year *

How often during the last year have you been unable to remember what happened the night before because you have been drinking? *

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

In the last year has a relative or friend, or doctor or other health worker been concerned about your drinking or suggested that you cut down? *

Yes No

SOCIAL HISTORY

ARMED SERVICES

Have you ever served in the armed forces? *

Yes No

If so can you provide us with copies of your medical records from your time in service?

Yes No

Are you experiencing any health problems relating to your time in the services? If so please list below

PATIENT ETHNIC ORIGIN

Please indicate your ethnic origin. This is not compulsory , but it may help with your healthcare, as some health problems are more common in specific communities and knowing your origins may help with early identification of some of these conditions

Any other ethnic group please let us know below

First language? *

THANKS

THANK YOU FOR TAKING THE TIME TO PROVIDE THE ABOVE INFORMATION, WE HAVE COMBINED 2 FORMS INTO ONE SO YOU ONLY NEED TO COMPLETE AND SUBMIT ONE FORM.

WE WILL PROCESS YOUR APPLICATION AS SOON AS WE CAN. IF YOU HAVE CHECKED YOUR POSTCODE AND ARE CLASSED OUT OF AREA YOU MAY RECEIVE A CALL FROM US BEFORE WE CONFIRM REGISTRATION.

THANK YOU #teamhoad

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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New Patient Registration Form (GMS1) + Health questionnaire

THANK YOU FOR TAKING THE TIME TO PROVIDE THE ABOVE INFORMATION, WE HAVE COMBINED 2 FORMS INTO ONE SO YOU ONLY NEED TO COMPLETE AND SUBMIT ONE FORM.

WE WILL PROCESS YOUR APPLICATION AS SOON AS WE CAN. IF YOU HAVE CHECKED YOUR POSTCODE AND ARE CLASSED OUT OF AREA YOU MAY RECEIVE A CALL FROM US BEFORE WE CONFIRM REGISTRATION.

THANK YOU #teamhoad

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