Register with a General Medical Practitioner (GMS1)

General Medical Practitioner (GMS1)

Application to register with a General Medical Practitioner

Please help us by completing the following information. This is very important as it may take some weeks for your medical records to arrive. Click here to download form.

Patient's Details - Please complete the text boxes and tick where appropriate.

Title:(*)

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First Name(s):(*)

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Previous Surname:(*)

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Sex:(*)

MaleFemale

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Home Address:(*)

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Surname:(*)

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Forenames:

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Postcode:(*)

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Email address:

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Telephone numbers:

Please remember to let us know if your contact details change in case, we need to contact you urgently.

Home:

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Work:

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Mobile:

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Date of Birth (DD/MM/YYYY):(*)

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Birth Town:(*)

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Birth Country(*)

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NHS No.: (*)

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What do you prefer to be called?

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

Name of previous GP while at previous address:(*)

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Your previous address in UK:(*)

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Address of that Doctor:(*)

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If you are from abroad

Your first UK address where registered with a GP:(*)

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If previously resident in UK, date of leaving (DD/MM/YYYY):

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Date you first came to live in UK (DD/MM/YYYY):

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If you are returning from the armed forces

Address before enlisting:

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Service or Enlistment Personnel number:

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Enlistment date(DD/MM/YYYY):

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If you are registering a child under 5:

I wish the child above to be registered with the named doctor for Child Health Surveillance

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If you need your doctor to dispense medicines and appliances:

I live more than 1 mile in a straight line from the nearest chemist

I would have serious difficulty in getting them from a chemist

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*Note: all doctors are authorised to dispense medicines

Signature of patient:(*)

Sign Above

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Signature of patient (DD/MM/YYYY):(*)

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Signature on behalf of patient:(*)

Sign Above

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Signature on behalf of patient (DD/MM/YYYY):(*)

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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. Please tick the boxes that apply:

I want to register my details on the NHS Organ Donor Register

Signature confirming my agreement to organ/tissue donation:

Sign Above

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Date (DD/MM/YYYY):

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For more information, please ask at reception for an information leaflet or visit the website www.uktransplant.org.uk or call 0300 123 23 23.

NHS Blood Donor registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood:

Tick here if you have given blood in the last 3 years:

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Date (DD/MM/YYYY):

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For more information, please ask for the leaflet on joining the NHS Blood Donor Register My preferred address for donation is: (only if different from above, e.g. your place of work)

Address:

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Postcode:

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HA use only

Patient registered for:

GMSCHSDispensingRural Practice

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To be completed by the doctor

Doctors Name:

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HA Code:

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I have accepted this patient for general medical services

For the provision of contraceptive services

I have accepted this patient for general medical services on behalf of the doctor named below who is a member of this practice

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I am on the HA CHS list and will provide Child Health Surveillance to this patient or

I have accepted this patient on behalf of the doctor named below, who is a member of this practice and is on the HA CHS list and will provide Child Health Surveillance to this patient.

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Doctors Name, if different from above:

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HA Code:

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I will dispense medicines/appliances to this patient subject to Health Authority’s Approval

I am claiming rural practice payment for this patient.

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HA Code:

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Distance in miles between my patient’s home address and my main surgery is:

I declare to the best of my belief this information is correct and I claim the appropriate payment as set out in the Statement of Fees and Allowances. An audit trail is available at the practice for inspection by the HA’s authorised officers and auditors appointed by the Audit Commission.

Authorised Signature:

Sign Above

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Name:

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Practice stamp:

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Date (DD/MM/YYYY):

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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:

I understand that I may need to pay for NHS treatment outside of the GP practice

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

I do not know my chargeable status

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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:

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Print name:

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On behalf of:

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Date (DD/MM/YYYY):

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Relationship to patient:

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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?

YesNo

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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.

If yes, please enter details from your EHIC or PRC below:

Country Code (e.g. UK, DE etc.):

Name:

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Given Names:

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Personal Identification Number:

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Identification number of the institution:

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Identification number of the card:

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Expiry Date (DD/MM/YYYY):

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Date of Birth (DD/MM/YYYY):

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PRC validity period

(a) From (DD/MM/YYYY):

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(b) To (DD/MM/YYYY):

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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.

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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.

Occupation:

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I am a student at:

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How often do you exercise?

Times a week or not much:

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Your weight:

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Your height:

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Your blood pressure:

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Do you smoke?

YesNo

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I have never smoked.

YesNo

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How many cigarettes a day:

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How many years ago did you give up smoking?

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Would you like to give up smoking? Help and treatment is available here. Ask at reception.

Next of kin:

Name:

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Telephone number:

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Relationship:

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Address:

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Post code:

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Are you a carer:

YesNo

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Are you in receipt of Carer’s allowance?

YesNo

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Relationship to you:

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Name of person you are caring for:

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Name of medicine or substance:

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Are you a veteran?

YesNo

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What problem does it cause?

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Ethnicity:

Please tick the ethnic group which you feel most accurately describes you. These are National codes as defined by the 2001 Census.

White British:

British

Irish

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Any other White background:

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Mixed:

White and Black Caribbean

White and Black African

White and Asian

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Any other mixed background:

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Black or Black British:

Caribbean

African

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Any other Black background:

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Other ethnic groups:

Chinese

Any other ethnic group

Not stated

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Asian or British Asian:

Indian

Pakistani

Bangladeshi

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Any other Asian background:

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The Nuffield Practice

Register with a General Medical Practitioner (GMS1)

General Medical Practitioner (GMS1)

Further information