Application to Register with a General Medical Practitioner Step 1 of 2 50% Contact DetailsSurname* First Names* Previous Surname Birth Town* Birth Country* Home PhoneMobile PhoneI am a student at Gender Male Female D.O.B. Day Month Year NHS Number Address Street Address Address Line 2 City Postcode Email Previous Medical DetailsPlease help us trace your previous medical records by providing the followingYour previous address in UK Street Address Address Line 2 City Postcode Name of previous GP while at previous addressAddress of that Doctor If you are from abroadYour first UK address where registered with a GP Street Address Address Line 2 City Postcode If previously resident in UK, date of leaving Day Month Year Date you first came to live in UK Day Month Year If you are returning from the armed forcesAddress before enlisting Street Address Address Line 2 City Postcode Service/Personnel No. Enlistment date Day Month Year If you are registering a child under 5I wish 1 I wish the child above to be registered with the named doctor for Child Health Surveillance If you need your doctor to dispense medicines and appliancesI live 2 I live more than 1 mile in a straight line from the nearest chemist I would have serious difficulty in getting them from a chemist NHS Organ Donor RegistrationI 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: Any of my organs and tissue Kidneys Heart Liver Corneas Lungs Pancreas Any part of my body 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 Untitled Tick here if you have given blood in the last 3 years For more information, please ask for the leaflet on joining the NHS Blood Donor Register Preferred address for donation: (if different from above, e.g. place of work)Postcode Supplementary QuestionsPATIENT 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.Please tick one of the following boxes: 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 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.Other informationAre you a parent or guardian, filling out this form on behalf of a child under 16? Yes No Name of parent or guardian Relationship to patient Complete this section if you live in another EEA countryComplete 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. 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? Yes No If yes, please enter details from your EHIC or PRC below:Country Code Name: Date Day Month Year Identification number of the institution: Given Names: Personal Identification Number: Identification number of the card: Date Day Month Year PRC validity periodFrom Day Month Year to Day Month Year Untitled Please tick if you have an S1 (e.g. you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state) 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.