Previously been registered with the NHS in the UK

Footnote: 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

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 at reception. Alternatively for more information go to www.nhs.uk/nhs-services/visiting-or-moving-to-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.

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.

To keep health risks from alcohol to a low level, the UK Chief Medical Officers (CMOs) advise it is safest not to drink more than 14 units a week on a regular basis. The CMO also give guidance on drinking in pregnancy and single occasion drinking.

For more information about drinking guidelines and understanding units visit Drink Aware.

Turning Point

Turning Point offers you or a loved one a range of services depending on what you need, from detox and residential rehab to supported living and aftercare support. Click  here  to see more information. 

If you would like support with alcohol issues. Please tick the box below to be referred.

Free Latent TB Infection and Screening Programme

We are offering free testing to diagnose latent TB; treatment is easy and helps prevent developing TB in the future. Latent TB does not have any symptoms, therefore the only way to find out if the bacteria is not active in your body is to get tested. If you meet all the criteria below on either questions one or two, let one of our receptionists know or book an appointment with our Practice Nurse. We may also send you a text message after your registration inviting you in for an appointment.

Criteria 1

• Are you aged between 16-35?
• Have arrived in the UK within the last five years?
• Have lived in one of the countries listed below for more than 6 months?
• No history of TB either treated or untreated

Criteria 2

• Are you aged between 16-35?
• No history of TB either treated or untreated
• Ex-prisoner, alcohol misuse, current/ex-drug user
• Never screened for TB in the UK

List of high-incidence countries

Afghanistan, Angola, Bangladesh, Benin, Bhutan, Botswana, Burkina Faso, Burundi, Cote d’Ivoire, Cabo Verde, Cambodia, Cameroon, Central African Republic, Chad, Comoros, Congo, DRP Korea, DR Congo, Djibouti, Eritrea, Equatorial Guinea, Ethiopia, Gabon, Gambia, Ghana, Greenland, Guinea, Guinea Bissau, Haiti, India, Indonesia, Kenya, Kiribati, Laos PDR, Lesotho, Liberia, Madagascar, Malawi, Mali, Marshall Islands, Mauritania, Mauritius, Micronesia, Mongolia, Mozambique, Myanmar, Namibia, Nepal, Niger, Nigeria, Pakistan, Papua New Guinea, Philippines, Republic of Moldova, Rwanda, Sao Tome and Principe, Senegal, Seychelles, Sierra Leone, Somalia, South Africa, Sudan, Swaziland, Timor Leste, Togo, Tuvalu, Uganda, UR Tanzania, Zambia, Zimbabwe

If you do not return this form, a Summary Care Record will be created for you based on implied consent

NHS Organ Donor registration

For more information on organ donation please visit: www.organdonation.nhs.uk

NHS Blood Donor registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323

What happens to my information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.