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New Patient Registration - Adults

Welcome to Selly Park Surgery! Please note we will only be able to process your registration provided you are in our catchment area and have provided the neccessary information. If you are out of our practice area your registration forms will be rejected and you will need to find an alternative GP Surgery within your area to register with.

If you have regular medication please ensure you have a minimum of two weeks worth prior to registering with us to allow time for your registration to be processed. 

New Patient Registration - Adults
If you are new to the country and have never had an NHS number please enter that date you first entered the country. If you do not know your NHS number please contact your previous practice who will be able to provide you with this information,

It is your responsibility to keep us updated with any changes to your telephone number, email & postal address. We may contact you with appointment details, test results or health campaigns

Next Of Kin Details
Please help us trace your previous medical records by providing the following information
If you are from abroad
Were you ever registered with an Armed Forces GP
What is your ethnic group

Select the option that best describes your ethnic group or background from the options below

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 select one of the following statements

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.

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.

If yes, please enter details from your EHIC or PRC below

If yes please provide the surgery with a copy

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.

Communication Needs
Carer Details

If yes please provide the details below. Only add carer’s details if they give their consent to have these details stored on your medical record.

Please note we will not be able to discuss your medical record or any information relating to your medical records until a Carer's Agreement form has been signed in practice.

Medical History
Family History

Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent

Allergies
Current Medication
Alcohol

Please answer the following questions which are validated as screening tools for alcohol use

Smoking
Height, Weight & Blood Pressure
Women Only
If needed, please book appointment.
Electronic Prescribing
Patient Participation Group

We are committed to improving the services we provide. The Patient Participation Group is a mechanism for us to gain valuable feedback from our patients about their experiences, views and ideas for improving our services.

Sharing Your Health Record
Your Summary Care Record (SCR)
Online Access To Your Health Record

I wish to access my medical record & understand & agree with each statement:

Exercise

During the last week, how many hours did you spend on each of the following activities?


Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.


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