New Patient Registration

Patient's Details

Please specify:

Surname: *

Previous Surnames:

First Name(s) *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Gender *

Male

Female

Indeterminate

Marital Status:

Single

Married

Widowed

Cohabiting

Plymouth Address: *

Please include house name and/or number. If you are a student attending Plymouth University, please enter your University address.

Postcode: *

Town and Country of birth: *

Home Phone Number:

Mobile Phone Number: *

Work Phone Number:

Email Address: *

NHS Number:

Your preferred choice of contact:

Text

Phone

Email

Post

Can we contact you by text?

Yes

No

Can we contact you by email?

Yes

No

Do you consent to the surgery leaving messages on your phone?

Yes

No

We will not leave detailed messages on your phone, but may ask you to contact us or leave a simple mesage if we do not need to speak to you.

Ethnicity

Please specify:

Do you speak English? *

Yes

No

Do you read English? *

Yes

No

First Language: *

Emergency Contact

Full Name: *

Relationship to you: *

Phone Number: *

Are they your Next of Kin? *

Yes

No

Do you give us permission to discuss your medical records with them? *

Yes

No

Allergies

Do you have any allergies? *

Yes

No

Please specify what you are allergic to, what happens and when you had your first reaction: *

Previous Details

Previous address in UK: *

Please include postcode.

Name and address of previous GP: *

If you are from abroad

Once you have completed your online registration and it has been processed by our team you will receive an email asking you to reply with a photo of your BRP card. This will be deleted from our email account after 21 days.

If you are returning from abroad

Previously been a resident in the UK

Date you left the UK:

Please use this date format: DD/MM/YYYY.

Date you returned to the UK:

Please use this date format: DD/MM/YYYY.

Supplementary Questions

I am not ordinarily a resident in the UK

Ordinarily Resident

Please select one of the following statements:

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

Signature:

Print Name:

On behalf of:

Relationship to patient:

Date:

European Economic Area (EEA) Country

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

Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?

Yes

No

Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?

Yes

No

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.

EHIC/PRC

Country Code

3. Name

4. Given Names

5. Date of Birth

6. Personal Identification Number

7. Identification number of the institution

8. Identification number of the card

9. Expiry Date

PRC validity period - from:

PRC validity period - to:

S1 Form

Do you have an S1 Form?

I have an S1 form (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.

If you are returning from the Armed Forces

Enlistment date:

DD/MM/YYYY

Leaving date:

DD/MM/YYYY

Service or Personnel Number:

Address before enlisting:

If you are returning from the Armed Forces please complete our HM Forces Patient Form

If you are registering for a child under 5

I wish the child above to be registered with the doctor named for Child Health Surveillance

If you need you doctor to dispense medicines*

*Not all doctors are authorised to dispense medicines

I live more than 1 mile in a striaght line from the nearest chemist

I would have serious difficulty in getting them from a chemist

Signature:

Date:

Signature of patient

Signature on behalf of patient

Mobility

Do you have significant mobility issues

Yes

No

Are you housebound?

Yes

No

(Definition of housebound - A patient is unable to leave their home due to physical or psychological illness)

Carers

Do you have a carer? *

Yes

No

Are you a carer for someone? *

Yes

No

Name of carer:

Phone Number:

Address:

Do you give us permission to discuss your medical record with your carer?

Yes

No

Tell us whether you accept cookies

Patient's Details

Ethnicity

Emergency Contact

Allergies

Previous Details

If you are from abroad

If you are returning from abroad

Supplementary Questions

Ordinarily Resident

European Economic Area (EEA) Country

EHIC/PRC

S1 Form

How will your EHIC/PRC/S1 data be used?

If you are returning from the Armed Forces

If you are registering for a child under 5

If you need you doctor to dispense medicines*

Mobility

Carers

Flu