New Patient Registration – OneContact Patient Portal

Patient’s Details

Choice of Practice

Which of our sites would you like to be registered with?

Title

Gender

Name

First Names

Surname

Previous Surnames (if applicable)

Date of Birth

Town and Country of Birth

Marital Status

NHS Number, if known

Home Address

Postcode

Telephone Number

This must be a UK number

Mobile Number

This must be a UK Number

Are you happy for us to contact you by text message?

Yes

No

Are you happy for us to contact you by letter?

Yes

No

Are you happy for us to contact you by email?

Yes

No

Preferred contact method, (Tick one)

SMS

Phone

Letter

Email

Email Address

Please provide an email address as we aim to increasingly use this to communicate with patients

Confirm Email Address

Please help us trace your previous medical records by providing the following information (If you do not have a previous UK address or NHS GP please enter N/A)

Your previous address in UK

Postcode

Name of Previous Doctor, if known

Name of previous Practice
Also provide Address

Are you from Abroad?

Are you from abroad?

Yes

No

Date you first came to live in UK

Your first UK address where you registered with a GP
Enter “As above” if current address

If you have never registered with a GP in the UK, write NONE

Name and Address of first GP practice you registered with when you arrived in the UK

Ethnicity

We want everyone, no matter what their ethnic group, religion or culture, to be able to use our services. Providing this information helps identify some groups at greater risk of specific diseases, e.g diabetes

From the drop-down box please state your ethnicity

Please specify your ethnicity if not in the list above

Language

Main Spoken Language

Do you speak English?

Yes

No

Can you read English?

Yes

No

Do you need an interpreter when you see the doctor?

Yes

No

Please state which language AND dialect

Are you an Asylum seeker?

Yes

No

Are you a refugee?

Yes

No

Are you homeless?

Yes

No

Members of the Armed Forces & Veterans

Are you returning from the armed forces?

Yes

No

Address before enlisting

Service or Personnel number

Enlistment Date

Getting to the practice

Are you housebound and unable to get to the practice?

Yes

No

Please explain why you are unable to attend the surgery (if necessary) for an appointment

NHS Organ Donor registration

For more information, please ask for the leaflet on joining the NHS Organ Donor Register.

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

NHS Blood Donor registration

For more information, please ask for the leaflet on joining the NHS Blood Donor Register.

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: blood.co.uk.

Supplementary Questions

PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

Tick this box if you are not ordinarily resident in the UK

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

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

I do not know my chargeable status

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 www.nhs.uk/visitingengland.

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.

Signature (Print Name)

On behalf of (if signing for a child under 16 years of age or for someone else)

Relationship to patient