New Patient Registration Form (GMS1)

Fields marked "REQUIRED" are compulsory. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Your details will be held at the surgery for a limited period of time. You are required to present in person to sign your registration form and provide proof of your address. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 04/01/2024

Patient's Details

Title *

Surname *

First name(s) *

Previous Surname/s

Birth Town *

Birth Country *

Date of Birth *

NHS number

Sex *

Male

Female

Address *

Postcode *

Telephone *

I am a student at:

Email Address *

What is your preferred method of contact? *

Phone

Letter

Are you happy to be contacted or sent information electronically/via the APP? *

Yes No

Please help us trace your previous medical records by providing the following information

Your previous address in UK

Name of previous GP practice while at that address *

Address of previous GP practice *

If you are from abroad

Your first UK address where registered with a GP *

If previously resident in UK, date of leaving

Date you first came to live in UK

Were you ever registered with an Armed Forces GP

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.

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas

Regular

Reservist

Veteran

Family Member (Spouse, Civil Partner, Service Child)

Enlistment Date

Discharge date (if applicable)

Address before enlisting

Service or Personnel Number

What is your ethnic group?

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

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.

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.

Are you a parent or guardian, filling out this form on behalf of a child under 16?

Name parent or guardian

Relationship to patient:

Signed

Date

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

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. 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:

Given Names:

Date of Birth

Personal Identification Number:

Identification number of the institution:

Identification number of the card:

Expiry Date:

PRC validity period

a) From:

b) To:

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.

I have an S1 form

NEW PATIENT QUESTIONNAIRE

Please answer the following questions to allow Reception to help you.

Would you like to book routine appointments and order repeat prescriptions on the internet? Please make sure we have your correct email address above, to be able to send your log in details. *

Yes No

Would you like FREE text message appointment reminders and information about your health sent to your mobile phone? *

Yes No

FEMALE patients only - Are you pregnant? (if yes please ask reception for details of self-referral process)

Yes No

Have you been registered at the practice before? (if this was under a different name please print your previous name below) *

Family History

Father/Mother/Siblings/Children only. Please state yes or no and if answering yes which family member and approximate age.

Heart Disease

Stroke

Diabetes

Are you registered disabled?

Yes No

Whilst in the surgery please use the self testing area and record:

Please ask if you need help.

Blood Pressure *

Resting Pulse (beats per minute) *

Height (in metres) *

Weight (in KG) *

Smoking

Do you smoke? *

Yes No

If 'No', have you ever smoked? *

Yes No

If you do currently smoke, how many cigarettes or ounces of tobacco do you smoke per week? *

Would you like advice on giving up smoking? *

Yes No

Carers

Do you have a carer? *

Yes No

If yes, please give details

Are you a carer? *

Yes No

If yes, please specify if you are paid or unpaid

Paid

Unpaid

Current Medication

Has your previous GP prescribed any regular medication for you? If so, please provide written details of your medication - a repeat prescription request form, if possible. Your medication will have to be checked and approved by the doctors before we can issue you with further supplies.

Repeat Medication. Please state the following below - Name of Drug, Tablet Strength and Dosing Instructions. *

Have you any allergies to drugs/medication? If YES please list below the following - Name of Drug & What Allergic Reaction. *

How To Order Your Medications

Repeat medication can be ordered by emailing POD (prescription ordering direct) at shropshire.pod@nhs.net or calling the POD on 01952 580350 or online via patient access (you will need a USER ID and PASSWORD which can be obtained by contacting reception or by answering YES to the relevant question on page 1 of this form). Alternatively, you can drop your request into our green script box in the foyer (tick the items you require on your repeat slip and drop it into the green script box (use outside post box if surgery is closed).

You may changed your preferred pharmacy at any time by either telephoning the surgery or by filling in the relevant section on your repeat slip.

PLEASE BE AWARE WE ARE UNABLE TO TAKE REQUESTS FOR REPEAT MEDICATION OVER THE TELEPHONE HERE AT THE SURGERY.

Please state your nominated pharmacy *

Communication

How would you describe your First Language? (Please pick one category only) *

English

Other (please specify below)

Please specify:

Do you have any information or communication needs? *

Yes No

Please give details below so that we can aim to meet your communication needs where reasonably practicable *

Do you need an interpreter? *

Yes No

Alcohol Users Disorders Identification Test (AUDIT)

**1 UNIT IS THE SAME AS 1 STANDARD ALCOHOLIC DRINK**

Pint of regular Beer/Lager/Cider - 2 units

Alcopop or Can of Lager - 1.5 units

Glass of wine (175ml) - 2 units

Single measure of spirits - 1 unit

Bottle of Wine - 9 units

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.

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New Patient Registration Form (GMS1)

Further Information