Flitwick Surgery

Patient's Details

Please specify:

Surname: *

Previous Surnames:

First Name(s) *

Gender *

Male

Female

Indeterminate

NHS Number:

Home Address: *

Postcode: *

Town and Country of birth: *

Please complete at least one phone number.

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

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

Have you previously been registered in the UK with a GP? *

Yes

No

I have no previous address

Please state why you have no previous address: *

e.g. Previously / currently homeless or Newborn baby

Previous address: *

Please include postcode.

Name and address of previous GP:

If you are from abroad

Registering for the first time in the UK

Your first UK address where you were registered with a GP:

If you are returning from abroad

Previously been a resident in the UK

If you are returning from the armed forces

Address before enlisting:

Service or personnel number:

Elistment date:

End of service date:

Supplementary Questions

I am not ordinarily a resident in the UK

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.

Please select one of the following statements:

I understand that I may need to pay for NHS treatment outside of the GP practice

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

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.

Signature:

Print Name:

On behalf of:

Relationship to patient:

Date:

European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea

Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?

Yes

No

Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC)?

Yes

No

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.

EHIC/PRC

Please enter the details from your EHIC or PRC below.

Country Code:

3. Name:

4. Given Names:

5. Date of Birth:

6. Personal Identification Number:

7. Identification number of the institution:

8. Identification number of the card:

9. Expiry Date:

PRC validity period - from:

PRC validity period - to:

S1 Form

Do you have an S1 Form?

I have an S1 form (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.

NHS Organ Donor registration

If you would like to join the NHS Organ Donation Register please visit their website on: www.organdonation.nhs.uk/consent.do

NHS Blood Donor registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323

Patient Details

Occupation:

Please specify:

Height:

Weight:

Please list any other residents living at your address:

Are you registering someone: *

Under 5 years old

Between 5 and 16 years old

Neither of these options

Next of Kin

Full Name: *

Phone Number: *

Relationship to you: *

Address: *

If you need your next of kin to be able to discuss your medical records then please contact the surgery for advice on how to arrange this.

Nationality

Your main or first language spoken / understood:

If you need a translation service for a consultation then please let us know when you book your appointment.

Religion

Please specify:

Summary Care Record

The NHS Summary Care Record is an electronic record of important information about your health. It will be available to health care staff providing your NHS care.

Are you happy to have a Summary Care Record? *

Yes

No

You will also need to complete the Summary Care Record Opt Out form.

Sharing Records

Can we allow your healthcare records to be seen by other healthcare providers? *

Yes

No

Can we see your healthcare records from other healthcare providers? *

Yes

No

Care.Data

Care.Data is the sharing of medical records for research at national level.

Are you happy to give consent for Care.Data? *

Yes

No

Carers

Are you a Carer? *

Yes

No

Please give the Name / Address / Number of the person you care for: *

Do you have a Carer? *

Yes

No

Please give their Name / Address / Number: *

If you need your carer to be able to discuss your medical records then please contact the surgery for advice on how to arrange this.

Power of Attorney

Have you nominated someone to speak on your behalf? *

Yes

No

Please give their Name / Address / Number / Relationship to you and further details of any Power of Attorney that may be in place: *

Medical History

Please list any current medication you have on repeat prescription:

Any other significant medical conditions:

Please state any allergies/reactions to medication you have (please record medication AND reaction):

Family Medical History

Smoking

Are you currently a smoker? *

Yes

No

How many cigarettes / cigars / tobacco do you smoke per day?

If you have ever smoked but have stopped, what date did you stop?

Exercise

How often do you exercise in a week? *

Type(s) of exercise:

Under 5

The practice will be forwarding the following information on to the relevant Health Visitors attached to the area. Please confirm you are aware of this by signing and dating below.

Signature: *

Date:

5 to 16 year's old

The practice will be forwarding the following information on to the School Nursing team. This has been requested by the School Nursing team and is as a result of national recommendations (arising from the Laming enquiry into the death of Victoria Clumbie). School Nurses have a duty to ensure that they are aware of all school aged children who are registered with our Practice, attending school in our area/or living within our boundaries.

Please confirm you are aware of this by signing and dating below.

Signature: *

Date:

Names of Parent(s) or Guardian(s) - To be shared

Name: *

Relationship: *

Name:

Relationship:

Child's Information - To be shared

Name:

Date of Birth:

Current Address:

Previous Address:

Contact Numbers:

Current GP:

Flitwick Surgery, Highlands, Flitwick, Bedfordshire, MK45 1DW

Previous GP:

Name of Primary School:

Name of Secondary School:

Alcohol Consumption

Please only complete this alcohol questionnaire if you are registering someone aged 16+.

I do not wish to complete an alcohol screening test

This is one unit of alcohol:

And each one of these, is more than one unit:

How often do you have a drink containing alcohol?

How many units of alcohol do you drink on a typical day when you are drinking?

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

Total to Audit - C

This is your total score from the first part of the Alcohol Consumption.

Signature: *

Date:

Flitwick Surgery

CQC Inspected and RatedGOOD

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Flitwick Surgery

After you’ve completed the form

Patient's Details

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

If you are from abroad

If you are returning from abroad

If you are returning from the armed forces

Supplementary Questions

Ordinarily Resident

European Economic Area (EEA) Country

EHIC/PRC

S1 Form

How will your EHIC/PRC/S1 data be used?

NHS Organ Donor registration

NHS Blood Donor registration

Patient Details

Next of Kin

Nationality

Religion

Summary Care Record

Sharing Records

Care.Data

Carers

Power of Attorney

Medical History

Family Medical History

Smoking

Exercise

Under 5

5 to 16 year's old

Names of Parent(s) or Guardian(s) - To be shared

Child's Information - To be shared

Alcohol Consumption

This is one unit of alcohol:

And each one of these, is more than one unit:

CQC Inspected and Rated
GOOD

Submit self-monitoring health reviews
(if requested by the doctor or nurse):