New Patient Registration

If you would like to register with the practice please use this form. This form needs to be completed with every person that is being registered including a separate for each child.

To register as a new patient you will need to live within our practice boundary.

West Street Surgery is proud to be a safe surgery for everyone in our community.

In recognition of the barriers to healthcare access faced by people in vulnerable circumstances, including migrants, we commit to protecting the human right to health.

We will take steps to ensure that everyone in our community may fulfil their entitlement to quality healthcare.

In partnership with Doctors of the World UK, we will ensure that our practice offers a welcoming space for everyone who seeks to use our services. Mindful of our duties to uphold equality and human rights law, we will implement patient registration policies which do not discriminate based on race, gender, sexual orientation, immigration status or any other characteristic.

Supported by the Safe Surgeries initiative, we will ensure that our staff understand the specific barriers faced by migrants in vulnerable circumstances and that they are empowered to mitigate these barriers, where possible. We will ensure that a lack of identification or proof of address, immigration status or language do not prevent patient registration.

As a member of the Safe Surgeries community, we will endeavour to support other Safe Surgeries and, where appropriate, provide feedback to Doctors of the World UK to support the development of the network.

New Patient Registration

Patient's Details

Title *
Please use this date format: DD/MM/YYYY.
Gender at birth: *
Is your gender the same as you were assigned at birth? *
Have you changed your name on your records previously? *

We'll register you with the details provided at the start of this form, but if your previous GP doesn't have these details it's important that we know your previous name so we can find your records.

Which of the following best describes you? *
Which of the following best describes how you think of yourself? *
Any responses we send will go to this email address.
Can we contact you by text?
Can we contact you by email?

Ethnicity

Please specify the ethnic group you consider you belong to:
Do you speak English?
Do you read English?
Do you require an interpreter? *

Emergency Contact

Are they your next of kin?
Do you give us permission to discuss your medical records with them?

For Children Under 16

Are you homeschooled?

Allergies

Do you have any allergies?

Previous Details

Please include postcode.

If you are from abroad

Registering with the NHS for the first time in the UK
Please use this date format: DD/MM/YYYY.

If you are returning from abroad

Previously been registered with the NHS in the UK
Please use this date format: DD/MM/YYYY.
Please use this date format: DD/MM/YYYY.

Supplementary Questions

I am not ordinarily a resident in the UK

Ordinarily Resident

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 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.

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?
Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?

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.

EHIC/PRC

Please enter the details from your EHIC or PRC below.

S1 Form

Do you have an S1 Form?
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.

Armed Forces

Have you ever served in the British Armed Forces?

Carers

Do you have a carer?
Are you a carer for someone?
Do you give us permission to discuss your medical record with your carer?