FAMILY DOCTOR SERVICES REGISTRATION - GMS1

In addition to the form below, we also ask you to complete a Summary Care Record consent form. This is important, as it enables us to assess any immediate or long-term needs you may have, as well as obtaining basic details regarding your own and family history. Please complete one for each member of your family, they must be signed and handed in at reception.

Please complete and tick boxes as appropriate.

Patients Details

Title:Surname:First names:Previous surname/sHome Address:Postcode:Town and country of birth:Telephone Number:Date of Birth:NHS Number:Gender:

Please help us trace your previous medical records by providing the following information

Your previous address in the 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 of leaving:Date you first came to live in UK:

If you are returning from the Armed Forces

Address before enlisting:Service or Personnel number:Enlistment date:

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 all doctors are authorised to dispense medicines

Signature of patient

Signature on behalf of patient

NHS Organ Donor registration

I want to register my details on the NHS Organ Donor Register as someonewhose 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

Signature on behalf of patient

For more information, please ask at reception for an information leaflet or visit the website www.organdonation.nhs.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 preferred to donate blood.

Tick here if you have given blood in the last 3 years

Signature confirming consent to inclusion on the NHS Blood donor Register

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)

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 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 '

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

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 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 of the GP practice, including at a hospital.

Do you have a non-UK EHIC or PRC?

Yes

If yes, please enter details from your EHIC or PRC below:

Country Code

3: Name

4: Given Names

5: Date of Birth

6: Personal Indemnification Number

7: Identification number of the institution

8: Identification number of the card

9: Expiry Date

PRC validity period

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.

Have you been a patient at the Surgery before?

Health Questionnaire

Have you been a patient at the Surgery before?

Yes

If so what year?

Do you have any special communication needs?

Smoking habits?

Smoker

Never Smoked

Ex-Smoker

Would you like support to quit smoking?

Yes

Date ceased (if an ex-smoker)

What is your current height?

What is your current weight?

Do you have any of the following diseases?

Asthma

Cancer

Diabetes

Chronic Heart Disease

Chronic Kidney Disease

Chronic Lung Disease

Epilepsy

Stroke / TIA

Hypertension (high blood pressure)

Hypothyroidism (underactive thyroid)

Mental Health (give details below)

Previous Operations (give details below)

Please give details of any Mental Health, Previous Operations or any other significant medical history: Please give details of any Allergies:

Are you on current medication (repeat)?

Yes

You need to book in for a medication review with your registered GP before we can reissue.

Please give details of family (parents, siblings, grandparents) medical history, any major operations or whether they have any of the following conditions: Asthma, Cancer, Diabetes, Chronic Heart Disease, Chronic Kidney Disease, Chronic Lung Disease, Epilepsy, Stroke / TIA, Hypertension (high blood pressure), Hypothyroidism (under-active thyroid), Mental Health or Previous Operations:

Are you a full time carer for a dependant person?

Yes

If yes, please give name, address and telephone number:

Do you have a carer?

Yes

If yes, please give name, address and telephone number:

How did you hear about us?

NHS Choices

Surgery Website

Recommendation from a friend

Other

If 'Other' please give details

Are you aware of what a Summary Care Record is and that you will be automatically enrolled unless you opt out?

Yes

Would you like PatientAccess to enable you to book appointments, order prescriptions and view your medication and allergies history online? If yes please register via our home page link.

Yes

Send Your Request

Thank you! Your submission has been received!

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Kepple Lane, Garstang, Preston, PR3 1PB

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