• Application to Register with a General Medical Practitioner

    Application to Register with a General Medical Practitioner
    Patient's Details

    Please complete the text boxes and tick where appropriate

    DD slash MM slash YYYY
    Sex:
    Patient's Details
    If you are from abroad
    MM slash DD slash YYYY
    MM slash DD slash YYYY
    If you are returning from the armed forces
    DD slash MM slash YYYY
    If you are registering a child under 5
    If you need your doctor to dispense medicines and appliances
    DD slash MM slash YYYY
    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:
    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
    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.
    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.
    Please tick one of the following boxes:
    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.(Required)
    NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS
    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 the GP practice, including at hospital).
    Do you have a non-UK EHIC or PRC?
    If yes, please enter details from your EHIC or PRC below:
    DD slash MM slash YYYY
    DD slash MM slash YYYY
    PRC validity period
    DD slash MM slash YYYY
    DD slash MM slash YYYY
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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.

    Asthma Annual Review Questionnaire

    Asthma Annual Review Questionnaire

    Asthma Annual Review Questionnaire
    Contact details
    DD slash MM slash YYYY
    Questionnaire
    5. In the last month has your asthma interfered with your usual activities (e.g. housework, work, school etc)?
    6. Have you ever had your peak flow measured at the surgery?
    7. Are you happy with your inhaler technique?
    If you are not, did you know there is an online demonstration on the Asthma UK website or you could pop in and see our practice nurse for more advice.
    8. Have you ever smoked?
    If 'Yes', please answer the following:
    Do you smoke now?
    There are plenty of options available to help you quit. Is this something you would like us to contact you about?

    Change of Contact Details

    Change of Contact Details

    Change of Contact Details
    Sex(Required)
    DD slash MM slash YYYY
    Are you a student?(Required)

    Comments and Suggestions Form

    Comments and Suggestions Form

    Comments and Suggestions Form
    This is the easiest way to make a complaint or leave a comment for us.
    What kind of comment would you like to send? Remember this form is not for medical matters.
    Your comment is:
    Your contact details
    Do you agree to be contacted regarding this matter?(Required)

    New Patient Health Questionnaire for Adults

    New Patient Health Questionnaire for Adults

    New Patient Health Questionnaire for Adults
    Your contact details
    Title:
    DD slash MM slash YYYY
    Information about you
    Do you need an interpreter?(Required)
    Previous GP
    Proof of Identity and Address Provided
    Medical Information
    Have you ever suffered from? (tick as appropriate)
    Epilepsy
    Heart Attack/Stroke
    High Blood Pressure
    Cancer
    Eczema/Hay Fever
    Blindness/Glaucoma
    Diabetes
    Depression
    Asthma
    COPD
    Are you registered disabled?
    Have you ever refused treatment/screening of any kind?
    Are you allergic to any medicines?
    Have you ever suffered from? (tick as appropriate)
    Anxiety
    Depression
    OCD
    Bipolar Disorder
    Carers
    Do you have a carer?
    Are you a carer?
    Wills
    Do you hold a Living Will?
    (A Living Will is documentation regarding your personal wishes in respect of medical intervention at the time of serious illness)
    Women
    Have you ever had a cervical smear?
    Smoking
    Do you smoke?
    If 'No', have you ever smoked?
    Would you like advice on giving up smoking?
    Alcohol
    1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits
    Family History
    Next of Kin
    Contacting you
    For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)
    Untitled(Required)

    Repeat Prescription Request Form

    Repeat Prescription Request Form

    Repeat Prescription Request Form
    Patient 1 details
    DD slash MM slash YYYY
    You may request up to twenty separate items. Enter each drug and strength on your prescription. Untick the 'Required' box if you do not require the item this time. Please note that items will only be dispensed if they are included on your repeat prescription and a medication review is not pending
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    Repeat Prescription Request Form 2

    Repeat Prescription Request Form (Patient 2)

    Repeat Prescription Request Form
    Patient 2 details
    DD slash MM slash YYYY
    You may request up to twenty separate items. Enter each drug and strength on your prescription. Untick the 'Required' box if you do not require the item this time. Please note that items will only be dispensed if they are included on your repeat prescription and a medication review is not pending
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