Havergal Surgery - New Patient Registration

Fields marked "REQUIRED" are compulsory.. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

If your registration is incomplete, you will be contacted by the team to inform you of this. This includes if you do not live in the catchment area, you will be notified to register at a surgery closer to your address.

Once your registration has been processed, a member of the Admin team will contact you to book a new patient health check with the Health Care Assistant (HCA) if you are over the age of 18.

If the person registering is under the age of 16 then you will need to bring the following to the reception as well:

Birth Certifcate and Red Book/Proof of Immunisation History

Last Updated: 13/12/2023

Patients Details

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

If you have been registered at another GP practice within the UK before wanting to register at Havergal Surgery, please provide your previous address and GP details. This will assist in the registration process.

Your previous address in UK

Previous GP Details (Name of GP/Surgery and Address)

Address of that Doctor

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

Services in the Armed Forces

HAVE YOU EVER SERVED IN THE BRITISH ARMED FORCES? *

Yes No

Address before enlisting

Service/Personnel No.

Enlistment 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

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

Information About You

Medical Information

Under 18s Only

Carer Information

Do you have a carer? *

Yes No

If yes please give details

Are you a carer? *

Yes No

If yes please give details

Women Only

Have you ever had a cervical smear?

Yes No

If 'yes', please state when, where and the result

Men Only

Have you had a testicular examination? Choose as appropriate

Self Examination

Non-Self Examination

Would you like advice on testicular awareness?

Yes No

Smoking Status

Do you smoke? *

Yes No

If 'No', have you ever smoked? *

Yes No

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week?

Would you like advice on giving up smoking?

Yes No

Alcohol Status

Family History

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer.

Next of Kin details

The details must be someone who lives in the UK and has a UK number

Please give name, address, telephone number and relationship of next of kin *

INFORMATION SHARING CONSENT

The Practice may share your information with other healthcare professionals and services in relation to your care please sign below. However you can choose to stop your confidential patient information being used for purposes other than your own care and treatment. This choice is known as a national data opt-out, please visit Data Opt Out

Do you share consent? *

Yes No

Contacting you

Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders. *

Yes No

Signature

If you are registering a child under 5

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

If you need your doctor to dispense medicines and appliances

I live more than 1 mile in a straight line from the nearest chemist

I would have serious difficulty in getting them from a chemist

Signature *

Signature of patient

Signature on behalf of patient

Signed (Please electronically sign here) *

Date *

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Havergal Surgery - New Patient Registration

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