2022 New Patient Registration Form

Fields marked "REQUIRED" are compulsory. You should only send this form if you are sure that you are eligible to join this practice. 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: 11/02/2022

  • Patient's Details

    Sex (optional)
    We may like to contact you by TEXT with appointment reminders and other information. Please indicate if you are willing to be contacted in this way
    WE MAY LIKE TO CONTACT YOU BY EMAIL WITH APPOINTMENT REMINDERS AND OTHER INFORMATION. PLEASE INDICATE IF YOU ARE WILLING TO BE CONTACTED IN THIS WAY
    ONLINE SERVICES: Patients can access Appointment Booking & Cancellations and Repeat Prescription Requests online. Do you wish to have a logon and password to allow you to access these services?
    Electronic Prescription Service: Would you like your prescriptions to be sent to a pharmacy of your choice electronically?
    Carers: A carer is defined as a person of any age, adult or child, who provides unpaid support to a partner, chuld, relative, or friend who couldn't manage to live independently or whose health or wellbeing would deteriorate without this help. Are you a carer?
    Carers: Do you have a carer?
    ID: We are required to validate individual ID for all new registrations. Please provide an email copy to beechhousesurgery@nhs.net or bring to Reception of either...

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

  • If you are from abroad

  • If you are returning from the armed forces

  • Complete Registration

    If you are registering a child under 5 (optional)
    If you need your doctor to dispense medicines and appliances (optional)
    Signature (optional)

  • NHS Organ Donor Registration

     

    Everyone is on the NHS Organ Donor Register, unless you specifically opt out.

     

    To do this visit https://www.organdonation.nhs.uk/register-your-decision/do-not-donate/ or call 0300 123 23 23

  • 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)
    Language: Do you speak English?
    SMOKING: Are you interested in stopping? (if yes, we will arange for you to see our smoking cessation advisers
    Allergies: Do you suffer from any allergies?
    Are you adopted?
    Health - Are any of these conditions applicable to you personally or someone in your family? (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. (optional)

  • 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)
    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. (optional)

  • 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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