GPS Healthcare - New Patient Registration Form Jan 24

Please fill in all required fields. If you need support filling in the form please contact the health and wellbeing team by calling the main surgery number.

Last Updated: 22/01/2024

  • Patient's Details

    Please select where you would prefer your usual site to be, this would be be your first choice for a face to face appointment
    Date of Birth
    For example, 15 3 1984
    Sex
    Contact consent
    Preferred contact method
    Accessibility - If you require accessibility support please tick below:
    Whilst you are under no obligation to answer the following question, this information allows the practice to ensure services are provided where thay are needed and that our healthcare is tailored to your individual needs. Please remember that ALL staff within the practice are bound by strict rules of confidentiality and no one will disclose information without your permission. (optional)

  • Proof of Identity and Address Provided

    This is not mandatory, however it really assists us with the registration process. 

    Identity Document Type

  • What is your ethnic group?

    Please tick one box that best describes your ethnic group or background from the options below:

    White (optional)
    Mixed (optional)
    Asian or Asian British (optional)
    Black or Black British (optional)
    Other ethnic group (optional)
    Not stated (Not Stated should be used where the PERSON has been given the opportunity to state their ETHNIC CATEGORY but chose not to

  • Health Check Information

    Smoking Habits
    Exercise

  • Alcohol

  • Family History

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

  • If you are from abroad

    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

  • Current Medication

    Please give details of any medication which you take (prescribed or otherwise):

    I consent to Electronic Repeat Dispensing
    Yes / No If yes would do you give consent for them to deal with your health matters?
    Do you look after someone who is ill, frail, disabled or mentally ill?
    Please pass on my details to Solihull Carers
    Please refer me to Adult Care Services for assessment

  • Were you ever registered with an Armed Forces GP

    These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

    Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas (optional)
    Enlistment Date (optional)
    For example, 15 3 1984
    Discharge date (if applicable) (optional)
    For example, 15 3 1984

  • 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.

  • 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
    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.

  • DATA SHARING INFORMATION HOW WE CAN USE YOUR DATA TO IMPROVE YOUR CARE – YOUR CHOICES

    You need to let us know if you wish to give consent. Summary Care Record Your Summary Care Record will hold the following information: Allergies and adverse reactions Acute medication Repeat medication Discontinued medication in the last 6 months Your Summary Care Record could be accessed, with your permission, by participating hospitals throughout the UK if you needed care. A Summary Care Record will automatically be created on completion of your registration unless you advise us to the contrary in writing. If you do not wish to have a Summary Care Record created, please contact the surgery within 2 weeks of your registration. Your Care Connected This is a more detailed record that can be shared with local hospitals and community services throughout Solihull, Birmingham and Sandwell. This enables all organisations to share important details of your medical history along with investigations, test results, medication etc. The aim is to improve communication across local GP’s, hospitals and community services, avoid duplicating investigations such as blood tests and also prevent patients from having to repeat their “story” at every service. “Your Care Connected” Record will automatically be created unless patients advise the practice that they wish to opt out If at any time you wish to OPT OUT of the Summary Care Record please contact the surgery on 0121 796 2777. If at any time you wish to OPT OUT of Your Care Connected please contact the surgery on 0121 796 2777 

    Opt in

  • SystmOne Enhanced Data sharing

    The following service is an “Opt-In” Service. You do need to complete the section below so that we can record your wishes. If you don’t complete and return this form you will be asked when you attend the surgery, so please do read and consider your choices. SystmOne Enhanced Data Sharing SystmOne is a clinical computer system produced by a company called TPP. It lets NHS staff record patient information securely onto a computer. This information can then be shared with other clinicians, if needed and agreed by you, so that everyone caring for you is fully informed about your medical history, including medication and allergies. In Solihull, many GP practices, HEFT Community services, The Walk in Centre and Marie Curie all use SystmOne so that patients can really benefit from joined up care. With your permission we can make your medical record shareable (Sharing Out). You will then be asked, when you attend other services, whether you are happy for them to access your record for information to improve your care and you can make a decision for each individual service i.e. you may want the district nurses to be able to access your record but if you are attending the smoking cessation service, you may not feel that they need to see your record. You will also need to tell each service if you are happy for them to let your GP see details of the treatment you receive from that service (Sharing In). Further information can be obtained from reception if needed. Sharing Out – I would like to make my record shareable so that other services can access it when I give them my permission to Consent to share record 

    Opt in

  • Complete Registration

    *Not all doctors are authorised to dispense medicines

    If you need your doctor to dispense medicines and appliances*
    Signature
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