New Patient Registration Form

Before completing the form please check with the below link if you are in our catchment area.

Check to see I am in Kirton Medical Centres catchment area

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The field Are you registering? is required.
The field Title is required.
The field First name is required.
The field Last name is required.
The field NHS Number is required.
The field Date of birth is required.
The field What is your sex as recorded on your NHS record? is required.
The field What was your gender at birth? is required.
The field Your occupation is required.
The field Village, town or city of birth is required.
The field What postcode of your last GP surgery you registered with? (if this is your first time registering please input Kirton Medical Centre postcode: PE20 1DS) is required.
The field Current address is required.
The field Name of your previous GP practice (if this is your first time registering please input Kirton Medical Centre) is required.
The field Have you ever lived somewhere else in the UK? is required.
The field Phone number is required.
The field Name of next of kin is required.
The field Ethnicity is required.
The field Have you registered with a GP Practice before? is required.
The field Have you ever served in the UK Armed Forces or were you ever registered with a Ministry of Defence GP in the UK or overseas? is required.
The field Do you need an interpreter for your appointments? is required.
The field Are you a carer? is required.
The field What pharmacy do you want your prescriptions sent to? (We are a dispensing practice so if you'd like us to supply your prescriptions please put our address) is required.
The field Select your answer is required.
The field Have you ever had any of these conditions? is required.
The field What best describes you? is required.
The field How often do you drink alcohol? is required.
The field How many units of alcohol do you typically drink when you are drinking? 1 pint of 4% beer is 2.5 units. a small 125ml glass of wine is 1.5 units and a 25ml shot of spirits is 1 unit. is required.
The field How often have you had six or more units of alcohol on a single occasion in the last year? is required.
The field What is your weight? is required.
The field What is your height? is required.
The field Do you have any known allergies? is required.
The field Do you have any known mental health conditions? is required.
The field Do you have any known disabilities? is required.
The field Do you have any other medical conditions not yet stated? is required.
The field Give details of any medication you are taking (if none, please put none) is required.
The field Did you receive a blood transfusion before 1996? is required.
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Part A

Try to provide as much information as possible. If a question does not apply to you or the person you are registering write ‘Not applicable’ or ‘N/A

Section 1 (PART A)

Who is registering?

Are you registering? Required

Yourself (go to section 2 - patient details)

Someone else

Only provide your details if you are registering someone else.

Your name

Your relationship to the person you are registering

Your contact number

____________________________________________________________________

Section 2 - Details of patient registering

Title Required

First name Required

Last name Required

Middle name (if you have one)

Previous last name (if you have one)

NHS Number Required

Date of birth Required

What is your sex as recorded on your NHS record? Required

Female

Male

Intersex

Not specified or known

What was your gender at birth? Required

Male

Female

Your occupation Required

Village, town or city of birth Required

What postcode of your last GP surgery you registered with? (if this is your first time registering please input Kirton Medical Centre postcode: PE20 1DS) Required

Current address Required

Address 1

Address 2

City

Country

County

Postal Code

Name of your previous GP practice (if this is your first time registering please input Kirton Medical Centre) Required

Have you ever lived somewhere else in the UK? Required

Yes

Last address in the UK

Address 1

Address 2

City

Country

County

Postal Code

Phone number Required

E-mail

Name of emergency contact

Phone number of emergency contact

Their relationship to you

Name of next of kin Required

Phone number of next of kin

__________________________________________________________________

Section 3 - Patients under 18 years

For children under 12 months only

Where were they born?

England

Northern Ireland

Wales

Isle of man

Scotland

Outside the UK

Where was the mother living when the baby was born?

Address 1

Address 2

City

Country

County

Postal Code

For patients under 18 years

Did you attend any of the following?

School

Nursey

Home school

None of the above

Are any of these involved in your care?

Hospital specialist

Health worker

Social worker

None of these

Have you had all your routine vaccines?

Yes

Not sure

Did you get your routine vaccinations in the UK?

Yes

Don't know

_______________________________________________________________

Section 4 - Additional information

Please tick one box that best describes your ethnic group or background from the options below:

Have you registered with a GP Practice before? Required

Yes

If you have moved to the UK, what date did you arrive?

Have you ever served in the UK Armed Forces or were you ever registered with a Ministry of Defence GP in the UK or overseas? Required

Yes

If you were given a FMED133A form (sometimes called an FMED1 form) when you left the UK Armed forces, you should give this to your GP surgery

Do you need an interpreter for your appointments? Required

Yes

If so, what language

Are you a carer? Required

Yes

What is your relationship to the person you are caring for?

What type of carer are you?

Young carer, under 18

Paid as a job

Unpaid, but may get benefits

Foster carer

Do you have a carer

If Yes, what is your relationship to your carer?

Carer's contact telephone number

What pharmacy do you want your prescriptions sent to? (We are a dispensing practice so if you'd like us to supply your prescriptions please put our address) Required

Would you have serious difficulty getting medicines or appliances from your nearest pharmacy?

Yes

Do you want important information from your GP record to be available to other health and care professionals?

Your GP surgery needs permission to share important information from your GP record. This is called a Summary Care Record (SCR). Your SCR can only be shared with health and care staff across England who are providing you with direct care. It gives them access to vital information from your GP record.

1. Yes, share a Summary Care Record with additional information Includes details of your medicines, allergies, adverse reactions and additional information, which includes details of any significant illnesses and health problems, operations and vaccinations

2. Yes, share a Summary Care Record without additional information Includes details of your medicines, allergies and adverse reactions only

3. No, do not share a Summary Care Record Details of your medicines, allergies, adverse reactions and any additional information will not be shared with anyone involved in your direct care

Select your answer Required

1. Yes, share a Summary Care Record with additional information

2. Yes, share a Summary Care Record without additional information

3. No, do not share a Summary Care Record

____________________________________________________________________

Part B

Have you ever had any of these conditions? Required

Alzheimer’s disease or dementia

Asthma

Cancer

Diabetes

Epilepsy

Heart disease

High blood pressure (hypertension)

None of the above

Stroke

What best describes you? Required

I smoke

I have never smoked

I used to smoke

Quitting

If yes, how many cigarettes do you smoke a day?

If you have stopped, what was your stop date?

How often do you drink alcohol? Required

Never

Monthly or less

2 to 4 times a month

2 to 3 times a week

4 or more times a week

How many units of alcohol do you typically drink when you are drinking? 1 pint of 4% beer is 2.5 units. a small 125ml glass of wine is 1.5 units and a 25ml shot of spirits is 1 unit. Required

How often have you had six or more units of alcohol on a single occasion in the last year? Required

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

What is your weight? Required

What is your height? Required

Do you have any known allergies? Required

Do you have any known mental health conditions? Required

Do you have any known disabilities? Required

Do you have any other medical conditions not yet stated? Required

Give details of any medication you are taking (if none, please put none) Required

If yes, are any of these repeat prescriptions?

Yes

Do you or your carer need to be communicated in an accessible format? (Braille, audio, large format or easy read - if so, tell us what you need)

Do you or your carer need any reasonable adjustments to make your visit to the GP surgery accessible?For example, an audible or visual alert in the waiting room, access to a hearing loop or the support of a note taker.

Blood transfusions

NHS England is committed to identifying all those infected with a bloodborne illness no matter how it is transmitted. You may have received infected blood if you had a transfusion because of:
• an accident
• complications during childbirth
• surgery or medical treatment

The information you give will be used by your GP surgery to consider suitability for blood screening, in the unlikely event you were given infected blood.

Did you receive a blood transfusion before 1996? Required

Yes

I don't know

__________________________________________________________________

Part C - Patients from abroad

Information on eligibility to free care outside the GP practice

Anyone can register with a GP practice and receive free medical care from that practice. However, should you be referred for treatment outside the practice or need unplanned care, for example at a hospital, charges may apply if you are a visitor or temporary resident.

Some groups of visitors or temporary residents are eligible to receive this care free of charge. Documentation may be required to demonstrate eligibility.

Examples of those eligible include:

• refugees, asylum seekers, those receiving certain forms of state support

• suspected or confirmed victims of modern slavery and human trafficking

• temporary residents with a valid visa of over 6 months. You may have paid the immigration health surcharge with your visa application. Note that assisted conception services remain chargeable to this group

• visitors from the EEA will need to provide their EHIC (European Health Insurance Card), which covers immediately necessary unplanned treatment, or a S2 form which covers planned treatment.

Additionally, some services are free of charge to all visitors, including diagnosis and treatment for infectious diseases and sexually transmitted infections.

Immediate necessary care, maternity care and other urgent care that cannot wait until a chargeable visitor’s departure from the UK will not be withheld or delayed due to charges. But non-urgent treatment will not be given until full payment is received.

More information can be found in the patient leaflet available from the GP practice

Select the statement that applies to you

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

I do not have to pay for NHS treatment outside of the GP practice and have documents to prove this

I do not know if I have to pay for treatment

Part C - Patients from abroad (continued)

Giving us this information means that if you need NHS care outside the GP practice and you are entitled to that care without charge, it will be easier for you to demonstrate this entitlement.

We’ll use the information to establish your chargeable status in order to recover NHS costs from countries responsible for your healthcare where applicable. This will not impact your entitlement to register with the GP practice or to receive free GP services.

Tick one of the following

I have an S1 form issued by an EU or EEA member state

I am entitled to an EHIC card, but I do not have one

I have an EHIC card issued by an EU or EEA member state

I am in receipt of a European pension or benefit

I am in the UK as part of my employment

None of these

Enter details from your EHIC (only patients from abroad need to complete)

How will your EHIC and S1 data be used?

By using your EHIC for NHS treatment costs your EHIC 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 or S1 information will be shared with Business Service Authority for the purpose of recovering your NHS costs from your home country

Country code

Name

Given name

Personal identification number

Identification number of the institution

Identification number of the card

Expiry date

I agree to the privacy policy

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New Patient Registration Form

Before completing the form please check with the below link if you are in our catchment area.

Check to see I am in Kirton Medical Centres catchment area

Part A

Section 1 (PART A)

____________________________________________________________________

Section 2 - Details of patient registering

__________________________________________________________________

Section 3 - Patients under 18 years

For children under 12 months only

For patients under 18 years

_______________________________________________________________

Section 4 - Additional information

Do you want important information from your GP record to be available to other health and care professionals?

____________________________________________________________________

Part B

Blood transfusions

__________________________________________________________________

Part C - Patients from abroad

Part C - Patients from abroad (continued)

Enter details from your EHIC (only patients from abroad need to complete)

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