Registration Forms

Quote / Testimonial:

We are now accepting registrations for new patients in the Island and also for patients wishing to transfer from another GP Practice.

Registration Forms

Adult Registration Form

Child Registration Form

Secondary or Visitor Registration Form

Keeping your details up to date

Patient Registration Update / Amendments form for Adults and Children

Update your Details Form

Adult Primary Registration Form for adults aged 16 or over

Individual patient registration forms must be completed for each adult and young person over the age of 16. Please complete clearly all relevant sections of this registration form.

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When completing this form make sure you have with you a Photo ID, Utility bill dated within 3 months and your Social security card or green health card. You’ll be required to upload these documents in order to complete your registration request

1. Patient Information

Your Name

Title Given Name Family Name

Known as Optional

Date of birth

MM slash DD slash YYYY

Resident in Jersey since

MM slash DD slash YYYY

Jersey Social Security Number

Do you hold a Green Health Card?

Patients need a health card to get a subsidy when visiting General Practitioners (GPs). Health cards are issued if a resident has lived in Jersey for at least 6 months and have paid Social Security contributions. For the first 6 months after arriving in Jersey, new residents don’t hold a health card and will have to pay the full cost should they need to visit a GP or another health care provider.

Gender Identity

Marital Status

Ethnicity (a)

Ethnicity (b)

First Language (if not English) Optional

Reason for registering with the Practice

Transferring from another Jersey GP Practice

Re-registering with GP Practice

New resident in Jersey

2. Home Address and Contact Information

Current home address

House Name / Flat Name Number & Street Parish / Town Postcode

Mobile Tel No.

Home Tel No. Optional

Work Tel No. Optional

Consent to receive SMS

Personal Email Address

Email Address Confirm Email Address

Consent to receive emails

Preferred Method of Contact

3. Emergency Contact / Next Of Kin Information

Name

Title Given Name Family Name

Date of birth

MM slash DD slash YYYY

Relationship to the patient

Do you give consent to discuss your record?

Is this your Official Carer?

Is this your Next Of Kin?

Home address

House Name / Flat Name Number & Street Parish / Town Postcode

Mobile Tel No.

Home Tel No. Optional

Work Tel No. Optional

Email Address Optional

5. Children aged under 16 and you are Parent/Guardian

Registrations Form to be completed for all those registering with the practice

Children Full Name and Date of Birth Optional

list here all your children

6. Private Medical Insurance and Current Employer Information

The Patient is responsible for making all claims with their insurer

Employment

Employed Full-Time Optional

Employed Part-Time Optional

Self-employed Optional

Not employed but looking for work Optional

Not employed and not looking for work Optional

Homemaker Optional

Retired Optional

Student Optional

Prefer Not to Answer Optional

Work Industry

Accounting/Finance Optional

Advertising/Public Relations Optional

Aerospace/Aviation Optional

Arts/Entertainment/Publishing Optional

Automotive Optional

Banking/Mortgage Optional

Organisation Development Optional

Organisation Opportunity Optional

Clerical/Administrative Optional

Construction/Facilities Optional

Consumer Goods Optional

Customer Service Optional

Education/Training Optional

Energy/Utilities Optional

Engineering Optional

Government/Military Optional

Green Optional

Healthcare Optional

Hospitality/Travel Optional

Human Resources Optional

Installation/Maintenance Optional

Insurance Optional

Internet Optional

Job Search Aids Optional

Law Enforcement/Security Optional

Legal Optional

Management/Executive Optional

Manufacturing/Operations Optional

Marketing Optional

Non-Profit/Volunteer Optional

Pharmaceutical/Biotech Optional

Professional Services Optional

QA/Quality Control Optional

Real Estate Optional

Restaurant/Food Service Optional

Retail Optional

Sales Optional

Science/Research Optional

Skilled Labor Optional

Technology Optional

Telecommunications Optional

Transportation/Logistics Optional

Other Optional

Current Employer Optional

Insurance Provider Optional

7. Previous/Existing GP Information

This will be used to request previous medical record information

GP Name Optional

Name of GP Practice

Tel No. Optional

Reason for transferring

8. Patient Declaration, Confidentiality Agreement, Personal Data Statement and Communication

Your Personal Information (Data Protection and Patient Privacy):

The information collected on this application form will be used by First Medical Ltd (hereafter the ‘Practice’) for the purposes of healthcare related services and practice administration. Optional

Personal information we hold about you is processed for the purposes of ‘Employment and Social Fields’ (Article 8) ‘Medical Purposes’ (Article 15) and ‘Public Health’ (Article 16) of the Data Protection (Jersey) Law 2018. Optional

This may require your personal data including, relevant details of your medical history, to be shared with other approved healthcare providers for the purpose of referrals and for other lawful purposes related to the Practice procedures. Optional

Further information on how we hold and process your data can be found in our Data Protection and Patient Privacy Policy.

General Practice Central Services (GPCS):

All Jersey GP Practices and other approved healthcare service providers, such as the out-of-hours doctors, use a central medical records system known as EMIS. Optional

This allows access to a ‘shared medical record’ to ensure that the provider or clinician has immediate up-to-date and accurate information about your health and any current treatment you may be having. Optional

You do however have the right to ‘opt out’ of sharing some or all of your medical records. Please ask us for more information and where appropriate an Opt-in/Out Form for completion. Optional

All approved healthcare service providers with authorised access to GPCS have signed strict confidentiality agreements which are bound by the Data Protection (Jersey) Law 2018.

Your Declaration to us:

• I confirm that all the information I have given in this registration form is accurate to the best of my knowledge.

• I understand that the Practice has the right to accept or decline my registration application at any time.

• I understand that by attending a consultation with a GP or other healthcare professional of the Practice, I accept the Practice terms of service and fee schedule issued and displayed in the Practice premises and as amended from time to time.

• I hereby agree to pay any incurred service fees from the Practice at the time of attendance or treatment.

• I expressly consent that on registration or prior to accepting any credit arrangement from the Practice, where appropriate a credit reference check may be taken with an authorised credit reference agency and/or my previous medical practice(s).

• I give my express permission for the Practice to request information including my medical records from my previously registered GP and I agree to reimburse the Practice for any charges and disbursements incurred relating thereto for the Practice being provided with such information.

• I understand it is my sole responsibility to advise the Practice in writing of any changes made in respect of my personal information.

Photo ID

Max. file size: 1 GB.

Valid passport, driving license or identity card

Proof of address

Max. file size: 1 GB.

Utility bill dated within 3 months; this document must have your name

Green Health Card

Max. file size: 1 GB.

if you don’t hold a green card, please upload copy of your Social Security Card. However, without a green health card you will be charged full price until the card is presented

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