New Patient Registration

 

BACK TO MAIN INDEX

 

Please complete our online form

Page {{ paginatorProps.current }} of {{ paginatorProps.total }} ({{ paginatorProps.percentage }}% completed)
Patient's Details

Information we need to register you with the practice
Please note all fields marked with a * are mandatory for your registration

Ethnicity & Religion
Emergency Contact
Allergies
Previous Details
Please include postcode
If you are from abroad
Please use this date format: DD/MM/YYYY
If you are returning from abroad

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
Were you ever registered with an Armed Forces GP

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

Supplementary Questions

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.

European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea

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.

Please enter the details from your EHIC or PRC below.

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.

Carers
 
Processing
Lifestyle
Your Personal Alcohol Consumption

alcohol consumption Image 1 unit

Audit Score Result

you have a score of 

If you are drinking less than 14 units of alcohol per week, then your drinking is within the UK Chief Medical Officers' low risk drinking guidelines.

But if you are drinking regularly at or above the low risk guidelines of 14 units a week, or, you are drinking six or more units - if you are female - or eight or more units - if you are male - in one single session (binge drinking), please consider the increased serious risks to your health being caused by your current drinking pattern.

 
Processing
Adult Females
Please use this date format: DD/MM/YYYY.
Immunisation History
Please include dates.
Medical History
Please include dates.
Please include dates.
Please include dates.

Over 75 years old?

The Department of Health has advised that all patients of 75years and older have a named and accountable GP to oversee their care. Please ask the name of the GP assigned to oversee your care. Please note this does not prevent you from seeing the GP of your choice.

 
Processing
Summary Care Record

Summary Care Record (SCR)

The Summary Care Record (SCR) system is designed to help both your GP and any emergency staff you contact when the surgery is closed to treat your health needs more efficiently.

Your information will be shared between your GP practice, our local hospital and Out Of Hours service. This will enable your GP surgery to access results and any visits you have at the hospital quickly and efficiently, but it also means that if you have an emergency and contact the Out Of Hours service or visit A&E they will have access to your current medications as well as allergies and are better able to treat you.

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

Dear Patient,

There are currently three different data sharing schemes running nationally; Local Data Sharing, the Summary Care Record and NHS Digital Data and Information Collection data sets.

It is important that patients know the difference between Local Data Sharing, the Summary Care Record and NHS Digital Data and Information Collection data sets, so that an informed choice can be made about whether you are happy for your data to be shared, or whether you wish to opt out.

We want to be sure that we give you the opportunity to decide at what level you would like to opt out of data sharing and are aware of the implications.

You can also opt out of receiving text messages from the surgery. The surgery sends texts relating to your appointments, health reminders or campaigns. Please ensure we have your correct mobile number if you want to receive these texts.

Please complete the attached form and return it to us so we can be clear about your wishes.

A data sharing agreement exists between other clinical services that we refer you to. There are local services that are run as a federation of practices; caring for patients and providing cover Monday to Sunday 8-8 at the Hub.

If a patient does not opt out, their information will be shared when immediate patient care is needed.

A Summary Care Record is an electronic record that is stored at a central location. It contains information about medicines, allergies, or reactions to medicines that a patient has had. The record does not include detailed information about a patient’s medical history. Only healthcare staff directly involved in the patient’s care who have access to this information. Having this information stored in one place makes it easier for healthcare staff to treat patients in an emergency. The information being shared could be critical in an emergency situation. If a patient does not opt out, they will automatically have a Summary Care Record; however a patient can opt out of or re-join the scheme at any time.

The NHS would like to link information from all the different places where patients receive care, to help them compare the care patients receive in one area against another, so they can see what has worked best. Information such as a patient’s postcode and NHS number, but not their name, will be used to link their records in a secure system, so their identity is protected. Information which does not reveal their identity can then be used by others, such as researchers and those planning health services, to make sure the NHS provide the best care possible for everyone. How patient information is used and shared is controlled by law and strict rules are in place to protect patient privacy. If a patient does not opt out, their information will be shared; however a patient can opt out of or re-join the scheme at any time.

 
Processing
Identification Upload

Patient Identification

To fully register you at the practice, we need Two forms of Acceptable ID (if not possible, please let us know).

We will not store these documents and we will securely delete / destroy them after our initial verification.

OPTIONAL: Photo of your face to add to your records to help us identify you (if you agree)

Acceptable Identification: Photo Driving License, Passport, Tenancy agreement, Mortgage statement, Bank statement, Utility bill (date within the past 3 months) etc.

Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
 
Processing

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

Dignity and Respect

Here at Ash Surgery we treat our patients with dignity and respect at all times, and expect the same in return.  We adhere to a zero tolerance policy.  Please sign below to agree to abide by these standards.

Patient Participation Group

Our surgery has a ‘Patient Participation Group’ This group plans to meet usually once a quarter to discuss our surgery, to get involved with any enhancements that we may be planning and to generally ‘help out’ if and when needed.

If you would like to be considered for a place within this group, as existing members leave or move out of our catchment area, please click below: 

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.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
Processing

There appears to be a problem loading the form, please refresh the page.
If the error persists please contact us.