New Patient Registration Form For Care Homes

This form is for Care Home staff to register new patients. Please use this form for all new residents including people already registered with the the Practice.

Please note that fields marked "REQUIRED" are compulsory and necessary to complete the registration.

Please continue to send additional information such as patient summaries, medication requests and hospital discharge letters for new residents.

Last Updated: 24/11/2022

Your Details

Please complete this section. Correct information will help us register you promptly and correctly.

Have you ever registered at this practice before? *

Yes

Title

Surname *

First name(s) *

Previous Surname

Birth Town *

Birth Country *

Date of Birth *

NHS number

Gender *

Male

Female

Other

Gender at birth (if different from above)

Male

Female

New Address *

Postcode *

NHS Records

There are strict laws and regulations to ensure that your health records are kept confidential and can only be accessed by health professionals directly involved in your care. There is some sharing of information as detailed below. You can opt out of any of these at any time if you wish.
NHS Summary Care Record (SCR) - this is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had. Having this information stored in one place makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed.

Please add your Summary Care Record preference here *

I agree to opt in

I do not agree to opt in

Please help us trace your previous medical records by providing the following

Your previous address in UK

Name of previous GP while at previous address *

Address of that Doctor Surgery *

If you are from abroad

Your first UK address where registered with a GP

If previously resident in UK, date of leaving

Date you first came to live in UK

If you are returning from the armed forces

Are you a Veteran of the Armed Forces

Yes No

Address before enlisting

Service/Personnel No.

Enlistment date

Registration Signatures

Signed by patient or on behalf of the patient *

Date *

NHS Organ Donor Registration

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. For more information, please ask for the leaflet on joining the NHS Organ Donor Register

Please tick the boxes that apply:

Any of my organs and tissue or

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

Any part of my body

Signature confirming consent to organ donation

Date

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

Date

Preferred address for donation: (if different from above, e.g. place of work)

Postcode

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 tick one of the following boxes:

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.

Are you a parent or guardian, filling out this form on behalf of a child under 16?

Name parent or guardian

Relationship to patient:

Signed

Date

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 the GP practice, including at hospital).

Do you have a non-UK EHIC or PRC?

Yes No

If yes, please enter 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

a) From:

b) To:

Please tick if you have an S1 (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.

I have an S1 form

Supplementary questions

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 TICK ONE OF THE FOLLOWING BOXES:

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

I do not know my chargeable status

2. 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.

Are you a parent or guardian, filling out this form on behalf of a child under 16?

3. NAME PARENT OR GUARDIAN

4. RELATIONSHIP TO PATIENT:

5. SIGNED

6. DATE

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.

Essential Information and Care Home status

Who is your Next of Kin / Emergency contact: Please state their relationship to the resident and provide an emergency contact number. *

Is there a Power or Attorney for Health and Welfare? Please document below

Is this person in a Residential or Nursing bed?

Nursing Home Bed

Residential Home Bed

Has this resident had a falls assessment?

Yes No

Does this resident have a care plan?

Yes No

Ethnic origin *

Any Other Ethnic Origin not listed above:

EPS- the electronic prescription service

EPS is a reliable, secure and confidential service. Your prescription can be sent electronically to a nominated pharmacy of your choice.

We would like to use the EPS service *

Yes No

Which Pharmacy would you like prescriptions sent to if not the usual care home nominee?

Health and Welfare Questions

Please list any known DRUG ALLERGIES or ALLERGIC REACTIONS:

Latest blood pressure reading if known

Please list any CURRENT MEDICATION, including inhalers. Please specify dose:

Please list any SIGNIFICANT MEDICAL CONDITIONS including major operations and dates:

Height

Weight?

New Patient Registration Form For Care Homes

Further Information