Ashurst Primary Care
New Patient Registration Questionnaire 
ALL INFORMATION WILL BE TREATED WITH THE STRICTEST CONFIDENTIALITY 	
Surname: 
	First Name(s):	
Mr   Mrs   Miss   Ms   Master   – please circle	
Address: 

Post Code:
(please bring proof of residency 1 X Photo ID 1 X Address ID such as utility bill)

Contact Number : Home

                              Mobile

                              E-mail address

Would you like to be a member of our E-patient participation group   Yes   No (please circle)	Date of Birth:

Place of birth:

Female/Male – please circle

Marital Status: 

Main Spoken Language:

Interpreter Required:                                    Yes      No

Date you first came to live in the UK………………………

Are you a registered carer?   Yes  No    please circle

Have you been in the armed forced?         Yes      No
(to aid in your medical care please can you provide a copy of your Army medical records)

Who lives in the household:
____________________________________
____________________________________
____________________________________

If you do not want the practice to contact you by our text messaging service –Opt out  	
Next of Kin:
Husband Wife Mother Father Other (please circle)
Address:

Post Code:

Contact number: Home

                                Mobile		
Name and Address of your current (last registered) GP 

Why are you changing your doctor? 
	
Have you been previously registered with this practice?                           YES   NO     please circle
	
Ethnicity: please tick 
White	
Mixed	
Asian or Asian
British	
Black or Black
British	
Other ethnic
groups	

British	
White and Black
Caribbean	
Indian	
Caribbean	
Chinese

Irish	
White and Black
African	
Pakistani	
African	
Any other ethnic
group (write in)	

Any other White
background	
White and Asian	
Bangladeshi	
Any other Black
background	

	
Any other Mixed
background	
Any other Asian
background	

	

Are you taking regular medication:                    Yes          No  (please circle)

We are unable to issue medication without proof. This can be provided by:
a  If you are on regular medication you previous GP is obliged to issue you with 1 month supply from date
    of leaving the practice
 
b if unable to obtain medication from your previous GP you would need to provide proof by either
   bringing in the right side of your prescription or the Packet or container your meds came in with name 
   and DOB	
  Medical problems (past/present)  (please list)

	
Smoking Status:    Please circle

                                Never            Ex-Smoker         Smoker             How many per day  ………………………..
                                E-Cig
	
Do you take alcohol?   Please circle

	 Yes	                    No                                             

if yes, please give details of your approximate weekly intake:
UNITS PER WEEK  
(as a guide ½ pint beer/larger, 1 single measure of spirit or 1 glass of wine = 1 unit)	
Do you have any Allergies?   YES       NO

If  you answered yes please list

	Height:

Weight:		
Do you use (or have you in the past used) any drugs (cannabis, amphetamines, heroin, methadone etc)?  YES    NO   ( If  YES to the above please list)

Is there a history of any of the following conditions in your family? If yes please give details	
Diabetes		
Heart attack/angina		
Stroke		
Asthma		
Cancer of any kind		
Any other significant history 

NHS Organ Donor Registration:

Kidney         Heart        Liver         Corneas         Lungs         Pancreas       Any part of my body
Signature confirming my agreement for issue/tissue donations
Name____________________________________Date_____________________________	
NHS Blood Donor Register
I would like to join the NHS blood donor register as some one who may be contacted and would be prepared to donate blood
Tick her if you have given blood over the past 3 years  
Signature confirming consent to inclusion on the NHS blood donor register  Date_______________
Name/signature_________________________________________

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:
a) I understand that I may need to pay for NHS treatment outside of the GP practice   
b) 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
c) 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.
A parent/guardian should complete the form on behalf of a child under 16.	

Signed:	
Date:	

Print name:	
Relationship to patient:	

On behalf 	

	

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.	

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC)DETAILS and S1 FORMS	

Do you have a non-UK EHIC or PRC?
	
YES: NO: 	
If yes, please enter details from your EHIC or PRC below:	

If you are visiting from another EEA 
country and do not hold a currentEHIC 
(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.	
Country Code:	

3: Name	

4: Given Names	

5: Date of Birth	

	
6: Personal Identification 
Number	

7: Identification number 
of the institution	

8: Identification number of the card	

9: Expiry Date	
DD MM YYYY	

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.	

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. 	

	

Accessible Information Standard

The Accessible Information Standard aims to make sure that disabled people have access to information that they can understand and any communication support they might need.
Should you have any requirements please let the Practice know
Please circle:	
Deaf/Hearing Loss	Visual Impairment/Blind	Learning/Mental Impairment	
Do you have any special communication requirements? 
i.e Use of a Hearing Loop		
Do you need a format other than standard print? 
i.e. Large print	
	
NB It is important to complete all questions, where a question is not relevant please enter NONE in the space

Patient Signature:………………………………………………………………….Date…………………………………..

OFFICE USE ONLY	
Date Received:                                  Address verified                     ID verified   	
Checked  by:        Name                                                                Signature	

NEW PATIENTS REGISTERING AT:

ASHURST PRIMARY CARE

YOUR NAMED ACCOUNTABLE GP FOR ASHURST PRIMARY CARE PATIENT’S IS:

DR S SAXENA

THIS MEANS DR SAXENA HAS OVERALL RESPONSIBILITY FOR YOUR HEALTH NEEDS WHILST REGISTERED AT THE PRACTICE

THIS DOES NOT AFFECT YOUR RIGHTS TO SEE A GP OF YOUR CHOICE