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New Patient Registration - Adults

New Patient Registration - Adults
Please help us trace your previous medical records by providing the following information
If you are from abroad
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.

If you need your doctor to dispense medicines and appliances*

* Not all doctors are authorised to dispense medicines

NHS Organ Donor registration

The law has changed so that you now need to opt out if you do not want to become a Donor. It is important that you talk to your family about your organ donation decision as they will be asked to support your decision. If you are undecided or do not want to become an organ donor please contact the NHS Organ Donation website at www.organdonation.nhs.uk or 0300 123 23 23.

NHS Blood Donor registration

All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.

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.

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 of the GP practice, including at a hospital.

If yes, please enter details from your EHIC or PRC below:

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 Information
Next of Kin

We would only contact your next of kin in an emergency. We do not divulge confidential information to anyone without your permission.

Our GP Online Service

Please read the Do It Online Leaflet for further information (available from the main registration page)

Life Style

Please answer the following questions which are widely used as screening tools for alcohol use

Your Needs
Medical History

Immunisations – Advise if you have had the following vaccinations, if you have please give date of last vaccination for

HIV

We have a high rate of HIV infection compared to the London and England average. As of 2018, our rate of diagnosed HIV is 8 in 1,000 residents. This is the 6th highest of a London borough. Estimates suggest that one in five people in London with HIV do not know that they have it. As of 2018, 44% of people in the borough diagnosed with HIV are diagnosed late and are already unwell.

You can find more information about HIV and AIDS in Lewisham routine testing here https://www.lewishamandgreenwich.nhs.uk/latest-news/hiv-testing-in-uhl-is-huge-success-09122019-1966/

If you like a test please speak to a receptionist Refusal: If despite medical recommendations if you do not want to have a test done then please let us know and we will make a record of it

Female Patients only

Cervical Smear Data

Eligible women for Smear Women are included in the cervical screening programme for the age of 25 to 64.

If you have not had a smear test in the last 3 or 5 years then please make an appointment with one of our practice nurse as soon as possible.

Having cervical screening at the recommended interval provides a low risk status rather than a no risk status of developing cervical cancer. A Cervical Information Booklet is available in English and number of other languages, you can find them on the NHS web site at: http://www.cancerscreening.nhs.uk/cervical/

Contraception

Please let us know the method of family planning/contraception you use

Breast screening

Breast screening is offered to all women aged between 50 and 70 every three years. Breast screening (Mammography) is the most reliable way of detecting breast cancer at an early stage which saves an estimated 1,400 lives each year. Every year around 11,500 people die from breast cancer in the UK. To find out more visit: www.cancerscreening.nhs.uk To book for your Breast Screening appointment please call 020 3299 1964

Ethnic Background/Origin

Please select what you consider your ethnic origin to be. Ethnicity is not the same as your nationality. For example, many of our patients whose nationality is British may also be from different ethnic groups such as Irish, Caribbean or Bangladeshi. It is important to us that you describe your own ethnic background/origin.


Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.


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