New patient registration

Patient’s details

Title

First names *

Last name *

Previous last name

Date of birth *

For example, 31/03/1980

Sex *

Male

Female

Other

As recorded on your medical record

Do you know your NHS number?

Yes, I know my NHS number

No, I do not know my NHS number

I’m not sure

This is a 10 digit number, like 485 777 3456. You can find it on any letter the NHS has sent you, on a prescription or by logging in to a GP surgery online service.

Your NHS number *

Town and country of birth *

Current home address *

Postcode *

Email address *

Any responses we send will go to this email address

Home phone number *

Mobile phone number *

Can we contact you by text? *

Yes

No

Can we contact you by email? *

Yes

No

Emergency contact

Emergency contact’s full name *

Emergency contact’s relationship to you *

Emergency contact’s phone number *

Are they your next of kin? *

Yes

No

Next of kin

Next of kin’s full name *

Next of kin’s relationship to you *

Next of kin’s phone number *

Previous details

Do you have a previous address in the UK?

Yes

No

Previous address in the UK *

Have you registered with a GP surgery in the UK before?

Yes

No

Name and address of previous GP surgery *

Have you moved to the UK from abroad?

Yes

No

Date you came to the UK *

For example, 31/03/1980

Have you previously lived in the UK and returned from abroad?

Yes

No

Date you left the UK *

For example, 31/03/1980

Armed Forces

Your answers will not impact your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services

Have you ever served in the UK Armed Forces or were you ever registered with a Ministry of Defence GP in the UK or overseas? *

Yes

No

Prefer not to say

Address and postcode before enlisting

Service or personnel number

Enlistment date

Discharge date

If applicable

Ethnicity

Specify your ethnic group *

Supplementary questions

Your answers will not impact your entitlement to register or to receive services from your GP

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.

Find out more about visiting or moving to England (opens in new tab)

Are you ordinarily resident in the UK?

Yes

No

Not ordinarily resident

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. A valid exemption includes for example, an EHIC, or payment of the Immigration Health Charge (“the Surcharge”), when accompanied by a valid visa. 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 (for example, 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.

You are declaring that the information given on this form is correct and complete. If it is not correct, appropriate action may be taken against you.

A parent or guardian should complete this section on behalf of a child under 16.

Do you understand your chargeable status? *

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

I have a valid exemption from paying for NHS treatment outside of the GP practice and have documents to prove this

I do not know my chargeable status

Signature *

Print name

On behalf of

Relationship to patient

Date

European Economic Area (EEA) country

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 Provisional Replacement Certificate (PRC)?

Yes

No

If you are visiting from another EEA country and do not hold a current EHIC or a PRC/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital

Do you have an S1 form?

Yes, and I will provide this to the surgery

No

For example, 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

Details from your EHIC or PRC

Country code

Name

Given names

Date of birth

For example, 31/03/1980

Personal identification number

Identification number of the institution

Identification number of the card

Expiry date

For example, 31/03/1980

PRC validity period from

For example, 31/03/1980

PRC validity period to

For example, 31/03/1980

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.

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Patient’s details

Emergency contact

Next of kin

Previous details

Armed Forces

Ethnicity

Supplementary questions

Not ordinarily resident

European Economic Area (EEA) country

Details from your EHIC or PRC

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