Under 16yrs Registration Form

Step 1 of 12

About you

Title

First name

Last name

Previous surname/s Optional

Gender

Date of birth

NHS number (If known) Optional

Place of birth

Contact details

Address

Street Address Address Line 2 Town Postcode

Telephone / Mobile Number

If you have a home phone number and mobile, please state both.

Email address Optional

Can we contact you by text?

Can we contact you by email? Optional

Ethnic group

White

British Optional

Irish Optional

Irish Traveller Optional

Traveller Optional

Gypsy/Romany Optional

Polish Optional

Any other white background Optional

Mixed

White and Black Caribbean Optional

White and Black African Optional

White and Asian Optional

Any other mixed background Optional

Asian or Asian British

Indian Optional

Pakistani Optional

Bangladeshi Optional

Any other asian background Optional

Black or Black British

Caribbean Optional

African Optional

Somali Optional

Nigerian Optional

Any other black background Optional

Other ethnic group

Chinese Optional

Filipino Optional

Any other ethnic group Optional

Not stated Optional

What is your main language?

Religion: Optional

Emergency Contact Information

Name

First Name Optional Last Name Optional

Relationship to you Optional

Contact Number Optional

Are they your next of Kin? Optional

Do you give us permission to contact them in an emergency? Optional

Allergies

Do you have any allergies? (this includes drug allergies)

If yes, please state what allergies and the severity: Optional

Extra Information

Are you a carer?

If yes, please state the name of who you are caring for, and their relationship to you: Optional

Are you being cared for?

If yes, please provide the following details of your carer:

First Name Optional Last Name Optional

Contact Number Optional

Please state their relationship to you: Optional

They could be a relative or just a carer

Do you give us permission to discuss your medical record with your carer if required? Optional

General Health

What is your eye sight like?

How is your hearing?

Please let us know if you have any other needs or requirements: Optional

Family History

Have any members of your family been diagnosed with the following: stroke, heart attack, diabetes, asthma, cancer or another serious illness not stated Optional

If yes, please state which family member, their relationship to you and what they had: Optional

Previous Details

Have you previously been registered with a GP in UK?

Yes

Your previous address in UK

Name of your previous GP practice

Address of your previous GP practice

Have you just moved to UK from abroad?

Yes

Your first UK address

Date you first came to live in UK

If you have previously been a resident in UK, date of leaving:

Date you returned to the UK:

Supplementary Questions

Consent

I accept the below statement

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.

Please tick if the statement applies to you:

I am not ordinarily a resident in the UK Optional

Please select one of the following statements:

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

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. Optional

I do not know my chargeable status Optional

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?

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

Country Code Optional

Name Optional

Date of Birth

Personal Identification Number Optional

Identification Number of the Institution Optional

Identification number of the card Optional

Expiry Date

PRC validity period - from

PRC validity period - to

Do you have an S1 form?

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

Do you give consent for a Summary Care Record?

Summary Care Record (SCR) is a national database that holds electronic records of important patient information such as current medication, allergies and details of any previous bad reactions to medicines, created from GP medical records. It can be seen and used by authorised staff in other areas of the health and care system involved in the patient's direct care, with the patients consent.

Pharmacy Nomination

Pharmacy Name Address Line 1 City Postcode

A nominated pharmacy is where we will send your prescriptions electronically to. As a new patient, if you are on any medication, please make an appointment to speak to the GP before you need further prescriptions.

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Under 16yrs Registration Form