Adult New Patient Registration Form

  • Patient Details
  • Health Information
  • Further Information
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Patient's Details

I declare to the best of my belief this information is correct. An audit trail is available at the practice for inspection by the HA’s authorised officers and auditors appointed by the Audit Commission.
Please use this date format: DD/MM/YYYY.

Ethnicity

Next of Kin & Other Relatives

Please include name, relationship & DOB.

Carers

Wheelchair/hearing aid/braille/lip reading etc.

Medical Records

Please help us trace your previous medical records by providing as much of the following information as possible.

If you are returning from the armed forces

Please use this date format: DD/MM/YYYY.

If you are from abroad

Please use this date format: DD/MM/YYYY.
Please use this date format: DD/MM/YYYY.

Supplementary Questions

Ordinarily Resident

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 go to www.nhs.uk/visitingengland.

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 16.