CFS New Patient Questionnaire & Registration Form

Patient Registration and GMS1 Form 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. Your details will be held at the surgery for a limited period of time. You are required to present in person to sign your registration form and provide proof of your address. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register. Last Updated: 09/12/2020

Last Updated: 23/12/2020

  • Your Contact Details

    Date of Birth
    For example, 15 3 1984
    Sex (optional)

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

    IF PREVIOUSLY RESIDENT IN UK, DATE OF LEAVING (optional)
    For example, 15 3 1984
    DATE YOU FIRST CAME TO LIVE IN UK (optional)
    For example, 15 3 1984

  • Information About You

    Do you need an interpreter?
    Ethnic Group

  • Medical Information

    Have you ever suffered from? (tick as appropriate) (optional)
    Are you registered disabled?
    Are you allergic to any medicines?
    Have you ever refused treatment/screening of any kind?
    Have you ever suffered from? (tick as appropriate) (optional)
    Do you have any other mental health issues?

  • 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? (optional)
    Date of Birth (optional)
    For example, 15 3 1984
    Expiry Date: (optional)
    For example, 15 3 1984
    a) From: (optional)
    For example, 15 3 1984
    b) To: (optional)
    For example, 15 3 1984
    Do 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. (optional)

  • IF YOU ARE RETURNING FROM THE ARMED FORCES

    Enlistment date (optional)
    For example, 15 3 1984

  • COMPLETE YOUR CHILD'S REGISTRATION

    If you are registering a child under 5 (optional)
    If you need your doctor to dispense medicines and appliances (optional)
    Date (optional)
    For example, 15 3 1984

  • Carers

    Do you have a carer?
    Are you a carer?

  • Women

    Have you ever had a cervical smear?

  • Will

    Do you hold a Living Will?

  • Smoking

    Do you smoke?
    If 'No', have you ever smoked?
    Would you like advice on giving up smoking?

  • Alcohol

  • Family History

  • Next of Kin

  • For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

  • SUPPLEMENTARY QUESTIONS | 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: (optional)
    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? (optional)
    Date (optional)
    For example, 15 3 1984

  • 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: (optional)
    Date (optional)
    For example, 15 3 1984

  • 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. (optional)
    Have you have given blood in the last 3 years (optional)
    Date (optional)
    For example, 15 3 1984

  • 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.

  • Signature

    Date
    For example, 15 3 1984

  • Proof of Identity and Address Provided

    For your registration to be processed please provide a copy of at least two of the documents listed below. You can email us a copy of the documents at chapeltownfamilysurgery@nhs.net

    Identity Document Type

  • 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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