Registration Form - Queens Crescent Practice

Are you completing this form on behalf of... *

Myself

Someone else (Please state your relation to them)Someone else (Please state your relation to them)

Have you registered for General Medical Services in the UK before? *

Yes, I have previously registered at a GP Practice in the UK and I have an NHS Number.

No, I have not registered at a GP Practice in the UK before, but I was born in the UK and I have an NHS Number.

No, I have not registered at a GP Practice in the UK before and I was not born in the UK, I do not have an NHS Number.

NHS Number *

How do I find my NHS number?

It is written on your NHS medical card.
Your old GP practice will have this information and will usually be happy to provide it to you over the phone.
Your NHS number is written on most hospital letters and appointment slips.
If you have not previously registered with an NHS GP in the UK an NHS number will not be required for registration with the Practice.

Example NHS Number:

About you

Title * Title

First Name(s) *

Calling Name

Surname *

Previous Surname

Gender *

Date of Birth *

Town of Birth *

Country of birth *

Borough of Birth *

Date of Arrival in the UK *

If previously resident in UK, date of leaving

Your Current Address

House Name/Flat number *

Number & Street *

Town/City *

County *

Post Code *

Country *

If you do not have an address please state why

Homeless

OtherOther

At my last GP Practice: *

I lived at a different address

I lived at my current address

Residency Status *

I am ordinarily resident in the UK.

I am not ordinarily resident in the UK.

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.

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.

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 choose one of the following options *

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

Non-UK European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC) Details and S1 Forms

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.

Do you have any of these?

Non-UK EHIC

PRC (Provisional Replacement Certificate)

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)

Country Code *

This code is on the card in the circle of stars

Personal Identification Number *

Institution ID *

Card / Certificate ID *

Expiry Date *

Valid From *

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.

Your previous address

House Name/Flat Number *

Number & Street *

Town/City *

County *

Post Code *

Country *

Your first UK Address where registered with a GP

House Name/Flat Number *

Number & Street *

Town/City *

County *

Post Code *

Country *

If you are returning from the Armed Forces

Service Number

Enlistment Date

Address before enlisting

House Name/Flat Number

Number & Street

Town/City

County

Post Code

Country

Contact Details

Primary Telephone *

Primary Tel Type *

Home

Mobile

Work

OtherOther

Secondary Telephone

Secondary Tel Type

Home

Mobile

Work

OtherOther

Tertiary Telephone

Tertiary Tel Type

Home

Mobile

Work

OtherOther

Email *

Before you register:

How do I find my NHS number?

About you

Your Current Address

Patient Declaration for all patients who are not ordinarily resident in the UK

Non-UK European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC) Details and S1 Forms

Please give your S1 form to the practice staff.

Your previous address

Your first UK Address where registered with a GP

If you are returning from the Armed Forces

Address before enlisting

Contact Details

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