Please complete all pages of this

patient registration form.

Upon completion, please follow the instructions on the last page.
 Patient registration form -
additional information
Please enter the name and address of the practice you are registering for in the space provided.

To register with this practice, please complete all forms as fully as possible.
The information will be used by our clinical team to make an initial
assessment of your current health and any future treatment required.
You should present two forms of identification when registering:
1) Proof of address (e.g. utility bill)
2) Photographic ID (e.g. passport or driving licence)

If you do not have these documents, please speak with a member of the
reception team who will be able to advise you further.

PATIENT DETAILS
Surname: Forename(s):

Date of birth: Marital status:

Telephone home: Telephone work:

Mobile number: Email:

Address:

Postcode:

Occupation/school:

SEXUAL ORIENTATION
Which of the following options best describes how you think of yourself?

P P
Lesbian/gay Bisexual
Heterosexual/straight In another way (please state below)

1
GENDER AND TRANS STATUS
Which one of the following options describes how you think of yourself?

P P
Woman (including trans woman) Man (including trans man)
Non-binary In another way (please state below)

Is your gender identity the same as the gender you were given at birth?

Yes No

NEXT OF KIN DETAILS

Name: Relationship:

Address:

Postcode: Telephone number:

CARER DETAILS
Are you a carer (this does not include caring for your own child/children)?
Yes n (If yes, please complete the details below) No n

I am a carer for (name):

Do you have a carer? Yes n (If yes, please complete the details below) No n

I am cared for by (name):

If you have a carer, would you like them to deal with your health concerns at the practice? Yes n No n

OTHER SERVICES INVOLVED IN YOUR CARE

Services P Contact details

Active case manager

Community psychiatric nurse

District nurse

Health visitor

Social worker

Other (please specify):

3
CHILDREN
Do you have any children or dependants under the age of 16?

Yes (If yes, please complete their details below) No

Name DOB Previous surname

Please state the name of the school they attend:

Are they on the child protection register? Yes No

MILITARY INFORMATION
Are you a military veteran? Yes No

If yes, do you consent to this information being recorded in your medical records? Yes No

YOUR MEDICAL HEALTH HISTORY

Do any of the following apply to you or a family member (father/mother/brother/sister)?
Please complete as much as you possibly can.

ADMIN NOTE: Please tick Year

Family member
INFORMATION USE ONLY Yes No diagnosed

Angina

Heart attack

Heart failure

High blood pressure

Peripheral arterial disease

Stroke

Arthritis - please specify type in

the space below:

Other rheumatic conditions

4
YOUR MEDICAL HEALTH HISTORY - continued

ADMIN NOTE: Please tick Year

Family member
INFORMATION USE ONLY Yes No diagnosed

Diabetes

Chronic kidney disease

Osteoporosis

Asthma

Other respiratory conditions

- please specify in the space
below:

Mental health conditions -

please specify in the space
below:

Dementia

Epilepsy

Learning disability

Cancer – please specify in the

space below:

IMMUNISATIONS
If this form is being completed for someone under the age of 25, please provide a copy of the
immunisation page of the child’s red book to ensure we have an up-to-date immunisation status.
This will help us to keep children vaccinated against infectious diseases.

MEDICATION
Please provide a copy of your latest prescriptions.
Choose a pharmacy for your prescriptions to be sent to.
Once you nominate a pharmacy:
 you will no longer need to collect paper prescriptions from your GP practice;
 your repeat prescriptions will continue to be sent to your nominated pharmacy until you change
or remove your nomination. Any outstanding prescriptions you have ordered may still arrive at
your current nominated pharmacy.

Please state the pharmacy name and address:

5
ALLERGIES
Are you allergic to any substances or foods? Yes No
If yes, please give details about what you are allergic to and the reaction you suffer from each:

SMOKING/TOBACCO USE
Please provide the following information related to smoking (please tick all that apply):

How much (oz)/

Smoking type P many per day?
Never smoked tobacco
Ex-smoker
Cigarette smoker
Cigar smoker
Pipe smoker
Roll own cigarettes
Use electronic cigarette
Chew tobacco
Other (please specify):

Passive smoking
Are you exposed to smoke at work? Yes No At home? Yes No

ALCOHOL USE

This is one unit Half a pint

of regular
Half a
small 1 single 1 small 1 single
of alcohol… beer, lager glass of measure glass of measure of
or cider wine of spirits sherry aperitifs

…and each of 2 3 2 3 9
1.5 4
these is more
than one unit.
Pint of regular Pint of strong Alcopop or a 440ml can of 440ml can of 250ml glass of 75cl bottle
beer, lager or or premium 275ml bottle of regular lager or super strength wine (12%) of wine
cider beer, lager or regular lager cider lager (12%)
cider

Scoring system Your

Audit score
(to be
0 1 2 3 4 completed by
the practice)

How often do you have an Never Monthly or

less
2 - 4 times per
month
2 - 3 times
per week
4+ times per
week
alcoholic drink?

When you drink alcohol, how 0 -2 3-4 5-6 7-9 10+

many units do you typically

consume?

6
ALCOHOL USE - continued

This is one unit Half a pint

of regular
Half a
small 1 single 1 small 1 single
of alcohol… beer, lager glass of measure glass of measure of
or cider wine of spirits sherry aperitifs

…and each of 2 3 2 3 9
1.5 4
these is more
than one unit.
Pint of regular Pint of strong Alcopop or a 440ml can of 440ml can of 250ml glass of 75cl bottle
beer, lager or or premium 275ml bottle of regular lager or super strength wine (12%) of wine
cider beer, lager or regular lager cider lager (12%)
cider

Scoring system Your

Audit score
(to be
0 1 2 3 4 completed by
the practice)

How often have you had six or Never Less than

monthly
Monthly Weekly Daily or
almost daily
more units if female, or eight or
more if male, on a single occasion
in the last year?

How often during the last year Never Less than

monthly
Monthly Weekly Daily or
almost daily
have you found that you were not
able to stop drinking once you
had started?

How often during the last year Never Less than

monthly
Monthly Weekly Daily or
almost daily
have you failed to do what was
normally expected from you
because of your drinking?

How often during the last year Never Less than

monthly
Monthly Weekly Daily or
almost daily
have you needed an alcoholic
drink in the morning to get
yourself going after a heavy
drinking session?

How often during the last year Never Less than

monthly
Monthly Weekly Daily or
almost daily
have you had a feeling of guilt or
remorse after drinking?

How often during the last Never Less than

monthly
Monthly Weekly Daily or
almost daily
year have you been unable to
remember what happened the
night before because you had
been drinking?

Have you or somebody else No Yes, but not in

the past year
Yes, during
the past year
been injured as a result of your
drinking?

Has a relative or friend, doctor No Yes, but not in

the past year
Yes, during
the past year
or other health worker been
concerned about your drinking or
suggested that you cut down?

Scoring: 0 – 7 lower risk, 8 – 15 increasing risk, Total

16 – 19 higher risk, 20+ possible dependence score

7
EQUALITY AND DIVERSITY
Belief/religion
P P
Atheism Judaism
Buddhism Sikhism
Christianity Other
Hinduism I do not wish to disclose
this information
Islam

DISABILITY
Do you consider yourself to be disabled/have an impairment?
Yes No I do not wish to disclose this information
If yes, please indicate below:

P
Blind or partially sighted
Dyslexia or Dyspraxia
Hearing or hearing impaired
Learning disability (Downs syndrome, Aspergers, Autism, etc.)
Mobility impairment
Manual dexterity or physical co-ordination

COMMUNICATION

Main spoken language:

Additional language(s) spoken:

If the patient is not at reading age yet, please

Main reading language:
state the parents/carer reading language.

Do you/the patient require any assistance with communication due to hearing, sight or speech
difficulties? Yes No
Do you require an interpreter? Yes No
Preferred method(s) of contact: Please number 1-5 in order of preference (1 being your preferred
option and 5 your least)

Details (e.g. telephone number, home/alternate address,

Preference Method
alternate format - Braille, large print, etc.)
Landline
Mobile phone
Text message
Email
Letter
If you require communication support for your appointments, please discuss with the receptionist
beforehand.
ETHNICITY
A. White P C. Asian or Asian
British P E. Other ethnic
P
groups
British
Indian Chinese
Irish
Pakistani
Any other white Any other ethnic
Bangladeshi group
background
Any other Asian I do not wish
background to disclose this
B. Mixed P information
White and Black D. Black or Black
Caribbean British P
White and Black African African
White and Asian Caribbean
Any other mixed Any other Black
background background

MIGRANT STATUS

Do any of the following apply to you? Yes No

Asylum seeker
Refugee
International student
Social migrant
Overseas visitor

FURTHER INFORMATION
Please let us know if you are interested in receiving information on any of the following:
1) For those aged 16-24, a free chlamydia test which can be done from the urine test you provide at
the new patient check Yes No

2) For those aged between 40-74, a free NHS health check Yes No
Please note this excludes patients with the following conditions:
Diabetes

Hypertension

Cardio-vascular disease

Chronic kidney disease

Currently receiving statins for high cholesterol

3) For those who smoke, a referral to a smoking cessation programme Yes No
4) Supporting the practice and helping to shape services by being part of a patient group
Yes No

Finally, please can you tell us where you heard about us?

9
 Thank you for completing
this questionnaire.
If you have had any difficulties completing the form,
please contact reception who will be pleased to assist.
We would like to welcome you to the practice and
hope that you will be happy with the service we
provide. We value your constructive comments or
suggestions to improve the workings of the practice.

FOR OFFICE USE ONLY

Proof of address and ID check list
Proof of address (Utility bill etc.):

Photographic ID (Driving licence, passport etc.):

Visa details (Passport number, visa dates etc.):

Member of staff name:

Member of staff signature:

Date:

10
 Family doctor services registration GMS1

Patient’s details Please complete in BLOCK CAPITALS and tick as appropriate

Surname
Mr Mrs Miss Ms

Date of birth First names

NHS Previous surname/s

No.
Town and country
Male Female of birth
Home address

Postcode Telephone number

Please help us trace your previous medical records by providing the following information
Your previous address in UK Name of previous doctor while at that address

Address of previous doctor

If you are from abroad

Your first UK address where registered with a GP

If previously resident in UK, Date you first came

date of leaving to live in UK

If you are returning from the Armed Forces

Address before enlisting

Service or Enlistment
personnel number date

If you are registering a child under five

I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance

If you need your doctor to dispense medicines and appliances* *Not all doctors are
authorised to
I live more than one mile in a straight line from the nearest chemist dispense medicines

I would have serious difficulty in getting them from a chemist

Signature of patient Signature on behalf of patient Date________/_________/_________

NHS Organ Donor registration

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation
after my death. Please tick the boxes that apply.
Any of my organs and tissue or
Kidneys Heart Liver Corneas Lungs Pancreas Any part of my body

Signature confirming my agreement to organ/tissue donation Date ________/________/________

For more information, please ask at reception for an information leaflet or visit the website
www.uktransplant.org.uk, or call 0300 123 23 23.

NHS Blood Donor registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.
Tick here if you have given blood in the last three years
Signature confirming consent to inclusion on the NHS Blood Donor Register Date ________/________/________

For more information, please ask for the leaflet on joining the NHS Blood Donor Register
My preferred address for donation is: (only if different from above, e.g. your place of work)
Postcode:

HA use only Patient registered for GMS CHS Dispensing Rural practice

042017_003 Product Code: GMS1

 Family doctor services registration GMS1

To be completed by the doctor

Doctors name HA code

I have accepted this patient for general medical services For the provision of contraceptive services
I have accepted this patient for general medical services on behalf of the doctor named below who is a member of this practice
Doctors name (if different from above) HA code

I am on the HA CHS list and will provide Child Health Surveillance to this patient or
I have accepted this patient on behalf of the doctor named below, who is a member of this practice and is on the
HA CHS list and will provide Child Health Surveillance to this patient.
Doctors name (if different from above) HA code

I will dispense medicines/appliances to this patient subject to Health Authority’s Approval

I am claiming rural practice payment for this patient.
Distance in miles between my patient’s home address and my main surgery is

I declare to the best of my belief this information is correct and I claim the Practice stamp
appropriate payment as set out in the Statement of Fees and Allowances. An audit
trail is available at the practice for inspection by the HA’s authorised officers and
auditors appointed by the Audit Commission.

Authorised signature

Name Date _______/_______/_______

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.
Please tick one of the following boxes:
a) I understand that I may need to pay for NHS treatment outside of the GP practice.
b) I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for

provide documents to support this when requested.

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

Signed: Date: DD MM YY

Print name:
Relationship to
patient:
On behalf of:

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.
NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC)
DETAILS and S1 FORMS
If yes, please enter details from your EHIC or
Do you have a non-UK EHIC or PRC? YES: NO:
PRC below:
Country Code:
3: Name
4: Given names
5: Date of birth DD MM YYYY
6: Personal identification
If you are visiting from another EEA number
country and do not hold a current 7: Identification number
EHIC (or Provisional Replacement of the institution
Certificate (PRC))/S1, you may be billed
for the cost of any treatment received 8: Identification number
outside of the GP practice, including of the card
at a hospital. 9: Expiry date DD MM YYYY
PRC validity period (a) From: DD MM YYYY (b) To: DD MM YYYY
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.
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.
Thank you for To submit the form, please follow the guidance below:
 save the form on to your desktop;
completing  go back to the ‘Register online’ page and upload the completed
patient registration form;
the patient  click submit (after verifying you have read the privacy policy);
registration form.  once submitted, the form will be sent to the GP practice for
processing.