Falcon

Patient's Details

Gender *

Male

Female

Other (please state)Other (please state)

Surname: *

Previous Surnames: *

First Name(s) *

Date of Birth: *

Please use date format DD/MM/YYYY

NHS Number

Town and Country of Birth: *

Home Address: *

Post Code: *

Email Address: *

Home Phone Number: *

Mobile Telephone Number

Work Phone Number:

Please tell us your preferred method of contact: *

Text Message

Email

Telephone

Post

Do we have permission to send you text messages? *

Yes

No

Previous Details

Previous address in UK:

Postcode:

If you are from abroad

Registering with the NHS for the first time in the UK

Date you came to live in the UK:

Please use date format DD/MM/YYYY

If you are returning from abroad

Previously been registered with the NHS in the UK

Date you left the UK:

Please use date format DD/MM/YYYY

Date you returned to the UK:

Please use date format DD/MM/YYYY

Supplementary Questions

I am not ordinarily a 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. 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.

Signature:

Print Name:

On behalf of:

Relationship to patient:

Date:

European Economic Area (EAA) 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

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:

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.

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 wish your medical records to be marked that you are willing to donate organs/tissue for transplantation after your death; please tick:

Signature:

Date:

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

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 3 years

Signature:

Date:

Personal Details:

Ethnicity: *

Occupation: *

Nominated Pharmacy Postcode: *

Nominated Pharmacy: *

Please detail below any specific needs you have:

This is so that the practice can ensure they are identified and accommodated by taking the appropriate action.

Are you a carer?

If you look after a member of your family or a friend who is unwell, frail or disabled, you are a carer.

Carers Details

Full Name:

Postcode:

Address:

Contact Number:

Date of Birth:

Are they a patient at this surgery?

Yes

No

Details of person being cared for

Full Name:

Postcode:

Address:

Contact Number:

Date of Birth:

Are they a patient at this surgery?

Yes

No

What relation is the carer?

Smoking

I am: *

A Smoker

An Ex Smoker

Not a Smoker

How many cigarettes do you smoke per day?

How much tobacco do you smoke per day?

What date did you quit smoking? *

Please use date format DD/MM/YYYY

Alcohol

A unit is half a pint of beer, a single spirit or a glass of wine.

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 units if male on a single occasion in the last year? *

Next of Kin

Full Name: *

Relationship: *

Contact Number: *

Application for online access to my medical record

I wish to have access to the following online services (please tick)

I wish to access my medical record online and understand and agree with each statement (tick)

I have read and understood the information leaflet provided by the practice

I will be responsible for the security of the information that I see or download

If I choose to share my information with anyone else, this is at my own risk

I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement

If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible

Signature:

Date:

In order to opt out of data sharing please ask at reception for further details.
If I don't opt out this means that my medical record will be made available to other medical organisations.

Practice Use Only

NHS Number:

Identity Verified by: (Initials)

Date:

Authorised by:

Date:

Method:

Vouching

Vouching with info in record

Photo ID and proof of residence

Date Account Created:

Date Passphrase Sent:

Notes:

Falcon

CQC Inspected and Rated
Good

We are currently CLOSED.

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New Patient Registration

Patient's Details

Previous Details

If you are from abroad

If you are returning from abroad

Supplementary Questions

European Economic Area (EAA) Country

S1 Form

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

NHS Organ Donor Registration

NHS Blood Donor Registration

Personal Details:

Are you a carer?

Carers Details

Details of person being cared for

Smoking

Alcohol

Next of Kin

Application for online access to my medical record

Practice Use Only

Tell us whether you accept cookies

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CQC Inspected and RatedGood

We are currently CLOSED.

Digital Practice Help

Make online requests to your GP Practice such as:

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

Find the forms that you need:

Give feedback to the Practice:

Get advice on common conditions:

Frequently Asked Questions

How do I make a request to my Practice?

How do I receive the responses from the Practice?

Security of your information

Tracking users

How is the Digital Practice updated?

Suggestions for improvement of the Digital Practice

Links to external sites

Falcon

Patient's Details

Previous Details

If you are from abroad

If you are returning from abroad

Supplementary Questions

European Economic Area (EAA) Country

S1 Form

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

NHS Organ Donor Registration

NHS Blood Donor Registration

Personal Details:

Are you a carer?

Carers Details

Details of person being cared for

Smoking

Alcohol

Next of Kin

Application for online access to my medical record

Practice Use Only

CQC Inspected and Rated
Good

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