New Patient Registration

If you would like to register with the practice please use this form.

To register a new patient you will need to live within our practice boundary.

Please read our welcome pack and relevant policies before completing your registration:

New Patient Registration

Patient's Details

Do you have any special communication needs? *

If you have stated that you have any special communication needs on this form, we will do our best to accommodate your needs. Should your needs change, please inform us.

Title *
Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
Please state which number you would prefer to be contacted on in the first instance: *
Can we contact you by text? *
Can we contact you by email? *

Previous Details

Do you have a previous address in the UK? *
Please include postcode.

About You

How would you best describe your gender? *
Is your gender identity the same the gender you were given at birth? *
How would you best describe your sexuality? *
Are you currently employed? *
How would you best describe your living status? *
Do you have a door access key code?

Ethnicity

What is your ethnic origin (Please tick the box that you feel best applies to you): *
Please specify your ethnic origin: *
Please specify your ethnic origin: *
Please specify your ethnic origin: *
Please specify your ethnic origin: *
If English is not your first language, do you require an interpreter to be arranged for your appointments?

Religion

What is your religion? *

Allergies

Do you have any allergies? *

If you are from abroad

Registering with the NHS for the first time in the UK
Are you from abroad and registering with the NHS for the first time? *
Please use this date format: DD/MM/YYYY.

If you are returning from abroad:

Previously been registered in the UK.
Please use this date format: DD/MM/YYYY.
Please use this date format: DD/MM/YYYY.

If you are returning from the Armed Forces:

Previously been registered with the NHS in the UK
Please use this date format: DD/MM/YYYY.
Please use this date format: DD/MM/YYYY.

Carers

Are you a carer? *
Would you like to be added to the practice's carers register to receive information: *
Do you have a carer? *

If yes, please provide their details below and sign if you authorise us to disclose information about your health to your carer.

Next of Kin

Are they registered at the practice? *

Medical Information

Do you suffer with sight loss?
Do you suffer with hearing loss?
Do you need help with mobility?
Do you suffer with a disability not state above?
Are you housebound?

Family History

Please give details of any close relatives who have had:

Medication

If you have a repeat medication slip from your previous GP, please attach to this form.

Electronic Prescribing Service: The practice can send your prescription to your preferred pharmacy electronically. Please inform us if you have nominated a pharmacy in another area and you now wish to change to a local pharmacy.

Health Information:

Female Patients

Have you ever had a cervical smear test done?
What was your last result?
Are you currently pregnant?
Have you ever been pregnant?

Relatives

Please use the following format: Name/Relationship/Date of birth

Supplementary Questions

I am not ordinarily a resident in the UK

Ordinarily Resident

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. Alternatively for more information go to NHS: Visiting England.

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 select one of the following statements:

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.

European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea
Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?
Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?

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.

EHIC/PRC

Please enter the details from your EHIC or PRC below.

S1 Form

Do you have an S1 Form?
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.

Smoking Status

Have you ever smoked tobacco? *
If you currently smoke, what do you smoke?
Do you use an electronic cigarette?
Are you interested in obtaining help to stop smoking? By ticking yes, you are agreeing to be referred to our stop smoking service here at Bridge Lane Group Practice:

Recreational Drugs

Do you use any recreational drugs?
Would you like to get advice on how these drugs may be affecting your health and receive help in stopping?

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol

Patient Groups

We have a group of patients who work with members of our practice team to improve the care and services that we provide.

We are keen to hear from all of our patients so that we can provide the best possible care to everybody.

Things that we have worked on recently include improving the care we provide to our patients with diabetes and improving how we are able to provide services to our patients who use wheelchairs. If you express interest below, we will contact you with more information about what we are working on and how you can join the group.

Would you be interested in joining our Patient Participation Group (PPG)? *

If you would like to give us feedback or to help us improve our services in a way but are not sure if you want to join the patient participation group, then send us an email or speak to any member of staff.

Online Access

If you wish to have online access via Patient Access in order to book appointments, request repeat prescriptions or to access your medical record, please complete the following.

Do you wish to register for online access? *
I wish to have access to the following online services:
Please complete the following to confirm that that you have understood and agree with each statement. (Please tick to indicate that you agree): *

Data Protection and Sharing

In accordance with the data protection act, the practice needs consent from any patient for us to leave a message, send a text or information regarding their medical treatment. By providing information on this form you are consenting to be contacted about your medical needs by the practice.

Regarding results, appointments or other medical issues relating to me:

I give permission to be contacted via text message: *
I give permission for a voicemail to be left: *
I give permission to be contacted via email: *

Data Research

To opt out of 'National Data' please visit www.nhs.uk/your-nhs-data-matters/manage-your-choice/

Summary Care Record

Summary Care Records (SCR) are an electronic record of important patient information, created from GP medical records. They can be seen and used by authorised staff in other areas of the health and care system only when involved in your direct care.

Giving your consent for authorised healthcare staff to have access to this important information means that they are able to make informed decisions particularly in an emergency or out of hours when your GP surgery is closed.

More information is available at: NHS: Summary Care Record Information

I wish to register for the Summary Care Record: *
Please tick the appropriate box:
Please confirm the following: *

Declaration

By signing this form, I confirm that I have read the following and agree to abide by the details included in each: *

We thank you for completing this form. If you require any more information on the practice, please return to our homepage after submitting this form. If your details change, or you would like to change your choices regarding how we contact you or share your data, please inform us.

Please provide a copy of your ID and Proof of address.
Maximum upload size: 67.11MB
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