New Patient Registration Form

To register at our GP Practice please submit this health questionnaire. Please then visit either surgery with your photo ID and proof of address to verify your identity (a driving license will meet both criteria).

Non-urgent advice: Patient Notice

Please provide us with as much information about yourself as you can so that the health records we hold for you are up to date.

Blood Pressure

Please use the machine in our waiting room to record your blood pressure and pulse rate or if you have your own BP monitor at home please record your readings below.

Contact Details

Title
First Name
Do you have a middle name?
Surname
Date of Birth
Full Address
Email

SMS Consent

Email Consent

Preferred Method of Communication

Next of Kin

Full Name
Email Address
Full Address

GP History

Please help us trace your previous medical records by providing the following information
Your Previous Address
Previous Address if from abroad

Background

Passport Status
EHIC
Armed Forces
Address Before Enlisting
Enlistment Date
Discharge Date

Communication Needs

Interpreter needed

Carer Details

Are you a carer?
Do you have a carer?
If you have a carer, do they consent for their details to be held on your medical record?
Carer Name

Family History

Do you have a family history of the following conditions – please tick all that apply:

Allergies

Do you have any allergies?

Medications

Are you currently on any medication?
If you need your doctor to dispense medicines, please tick the applicable boxes below

Alcohol Status

alcohol units

Smoking Status

What is your smoking status?

Join the millions of people who have used Smokefree support to help them stop smoking. From email and text, to our free app and lots of other support, you can choose what’s right for you.

For more information visit: www.nhs.uk/smokefree

Height and Weight

(in metres and cm)
(in kg)

Women Only

Contraception
Pregnancy

Blood & Organ Donations

Blood Donation
Organ Donation

Please make sure your family are aware if you wish to be an organ donor. If you do not want to be an organ donor please visit: www.organdonation.nhs.uk/ or call: 0300 123 23 23 to register your decision.

Data Sharing

There is a balance between privacy and good health care. We normally share information with other health care professionals involved in your care such as doctors, nurses, therapists and pharmacists.

Please tick to confirm your preference to the below data sharing options. Please note that the consent obtained within this section can be changed at any time.

Sharing out – do you consent to the health data recorded by Attleborough Surgeries to be shared with any other organisations that may care for you?
Sharing in – do you consent to the health data recorded by other care services to be viewed by Attleborough Surgeries?
Core Summary Care Record Preference – do you consent for your ‘core’ SCR to be shared with other organisations that may care for you?
Additional Summary Care Record Preference – do you consent for your ‘additional’ SCR to be shared with other organisations that may care for you?

Patient Declaration

I sign to confirm that the information I have provided is correct to the best of my knowledge and I will contact Attleborough Surgery if I am aware of any changes.
Clear Signature

Supplementary Questions – only applicable for 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. Alternatively for more information: www.nhs.uk/nhs-services/visiting-or-moving-to-england/

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.

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.

A parent/guardian should complete the form on behalf of a child under the age of 16.

Are you a parent/guardian completing the form on behalf of a child under the age of 16?
Clear Signature
Name

Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?
If you have an EHIC issued by the UK, please select ‘No’.

Non-UK European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC) details and S1 Forms

Do you have a non-UK EHIC or PRC?
non-uK european health insurance card (ehic)

If you are visiting from another EEA country and do not hold a current EHIC (or PRC/S1), you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

Date of Birth
Expiry Date
PRC Validity Period – From
PRC Validity Period – To
Do 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.

How will your EHIC/PRC/S1 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.