Kepple Lane, Garstang, Preston, PR3 1PB

Tel: 01995 607399

Contact Details

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FAMILY DOCTOR SERVICES REGISTRATION - GMS1

In addition to the form below, please read the information on your Summary Care Record. If you choose to opt out of holding a Summary Care Record, or register to share additional information alongside your medication, allergies and adverse reactions, please complete one for each member of your family and e-mail it to fwccg.gmpadmin@nhs.net. There is also an alcohol consumption questionnaire. If you choose to complete it please e-mail your results to fwccg.gmpadmin@nhs.net.

Organ Donation - The law around organ donation in England has now changed to an Opt out system. This means that all adults in England will be considered to have agreed to be an organ donor when they die unless they have recorded a decision not to donate or are in one of the excluded groups. However, it is still your choice. Please view the Organ Donation website for more details and how to opt out if you would prefer not to be a donor. An Easy Read guide is also available. You can also call 0300 303 2094 (Mon – Fri: 8am - 8pm; Sat and Sun: 8am - 4pm); Minicom: 0845 730 0106; Text chat: 07860 034343.

Please complete and tick boxes as appropriate.

Patients Details

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

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

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

Yes

No

Preferred pronouns: e.g., He/His, She/Her, They/Them:

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

Your previous address in UK: Name of previous GP practice while at that address: Address of previous GP Practice:

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:

Were you ever registered with an Armed Forces GP

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas:

Regular

Reservist

Veteran

Family Member (Spouse, Civil Partner, Service Child)

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

Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

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

Today's Date

What is your ethnic group?

What is your ethnic group?

Please select an option below that best describes your ethnic group or background:

White:

British

Irish

Irish Traveller

Traveller

Gypsy/Romany

Polish

Mixed:

White and Black Caribbean

White and Black African

White and Asian

Asian or Asian British:

Indian

Pakistani

Bangladeshi

Black or Black British:

Caribbean

African

Somali

Nigerian

Other ethnic group:

Chinese

Filipino

Other options:

Other (Enter below)

Not Stated

'Not Stated' should be used where the PERSON has been given the opportunity to state their ETHNIC CATEGORY but chose not to.

Any other background or other ethnic group (please enter if 'Other' selected):

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

Date

Print Name On behalf of

Relationship to Patient

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

EHIC card

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?

Do you have a non-UK EHIC or PRC?

Yes

No

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

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.

HEALTH QUESTIONNAIRE

Registration Information for Patients Under 18 Years Old

Who has parental responsibility for this child? (Person named on birth certificate or applied for legal parental responsibility).

Name: Telephone Number:

Is this child a looked after child?

Is this child a looked after child?

Yes

No

If Yes, please provide social worker name and contact number:

Does the child now or have they ever been a subject of a child protection proceeding?

Does the child now or have they ever been a subject of a child protection proceeding?

Yes

No

What educational establishment does the child attend?

Health Questions

Have you been a patient at the Surgery before?

Have you been a patient at the Surgery before?

Yes

No

If so what year?

Do you have any special communication needs?

Smoking habits?

Smoking habits?

Smoker

Never Smoked

Ex-Smoker

Would you like support to quit smoking?

Would you like support to quit smoking?

Yes

No

If a smoker, how many cigarettes/cigars etc. a day?

Date ceased (if an ex-smoker)

What is your current height?

What is your current weight?

Do you have any of the following diseases?

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)?

Are you on current medication (repeat)?

Yes

No

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?

Are you a full time carer for a dependant person?

Yes

No

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

Do you have a carer?

Do you have a carer?

Yes

No

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

How did you hear about us?

How did you hear about us?

NHS.uk

Surgery Website

Recommendation from a friend

Other

If 'Other' please give details

I have read the above information regarding the Summary Care Record (SCR) and understand unless I complete the form and return it to the practice immediately then a Summary Care Record containing information about my medication, allergies, adverse reactions and additional further medical information will be created for me.

We offer an SMS service for appointment reminders, invites, and to collect feedback on your experience of our surgery. You can opt out of this service at any time. Please tick the box to the left if you do not consent to receiving text messages from the surgery.

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