Online registration form for current NHS patients

Thank you for contacting Ashville Surgery, we will send you a text as soon as your registration is complete.

Patient's details

Title*

Surname*

Date of birth*

First names*

NHS Number*

Previous surnames

Gender*

Male
Female

Town and country of birth*

Ethnicity*

Religion*

Home address*

Postcode*

Telephone number*

Can we contact you by text or phone

I give consent for the Practice to contact me by SMS text message or e-mail with matters relating to my health and medical records
I do not wish to be contacted by the Practice by SMS text message or e-mail with matters relating to my health and medical records

Personal Details

Marital Status*

Sexual Orientation

If you choose Other (please describe this if possible)

Your previous address in UK

Name of previous GP practice while at that address

Address of previous GP practice while at that address

If you are from abroad

Date you first came to live in the United Kingdom

Please use this date format: DD/MM/YYYY.

Your first UK address where registered with a GP

If previously resident in UK, date of leaving

If you are registering a child under 5

I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance

If you need your doctor to dispense medicines and appliances*

I live more than 1.6km in a straight line from the nearest chemist
I would have serious difficulty in getting them from a chemist

What happens to my information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you. We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols. To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

Electronic Prescription Service (EPS)

The Electronic Prescription Service (EPS) is a NHS service that allows us to send your prescription(s) directly to your chosen pharmacy. This paper-free prescription service means that you do not have to come into the surgery to collect your prescription.

We encourage all patients to register for this free service.

Would you like to register for Electronic Prescription Service (EPS)?

Yes
No

I would like to register my Electronic Prescription Service (EPS) with the following pharmacy.

Pharmacy Name, Address and Postcode:

Patient Health Questionnaire

Emergency Contact

Name

First Last

Relationship to you

Phone

Are they your Next of Kin?

Yes
No

Do you give us permission to discuss your medical records with them?

Yes
No

Does this person lives in the same household as you?

Yes
No

Adult Females Only

When was your last cervical smear?

Was it done at

A Previous GP
A Family Planning Clinic

Have you had a hysterectomy?

Yes
No

NHS Blood Donor registration

For more information, please ask for the leaflet on joining the NHS Blood Donor Register

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 confirming consent to inclusion on the NHS Blood Donor Register

Signature*

Signature
Signature of behalf of Patient

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

Signature for non-residents (Print your name to sign)

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.

On behalf of

Complete this if you are signing for someone else

Relationship to patient

Complete this if you are signing for someone else

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.

Please enter the details from your EHIC or PRC below.

Country Code

Name

Given Names

Date of birth

Personal Identification Number

Identification number of the institution

Identification number of the card

Expiry Date

PRC validity period - from:

PRC validity period - to:

S1 Form

Do you have an S1 Form?

Yes
No

If YES - 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.

Consent*

I agree to the privacy policy.

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.

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Online registration form for current NHS patients

New Patient Registration Form - existing NHS patients

Thank you for contacting Ashville Surgery, we will send you a text as soon as your registration is complete.

Patient's details

Personal Details

Sexual Orientation

If you are from abroad

What happens to my information?

Electronic Prescription Service (EPS)

Patient Health Questionnaire

Emergency Contact

Adult Females Only

NHS Blood Donor registration

European Economic Area (EEA) Country

S1 Form

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

Helpful links: