Brunton Park New Patient Registration 240622

Please help us trace your previous medical records.
Have you moved to the UK from abroad?*

YesNo
Your previous address in the UK

Street Address

Street Address Line 2

CityCounty

Postal Code
Name and address of previous GP practice while at that address
What was your address when first registered with a GP?

Street Address

Street Address Line 2

CityCounty

Post Code
If previously resident in UK, date of leaving

DayMonthYear
Date
Date you first came to live in UK*

DayMonthYear
Date

Have you been in the Armed Forces?

ArmyRoyal NavyRoyal Airforce
Were you ever registered with an Armed Forces GP. 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. 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 charity services.

RegularReservistVeteranFamily Member (Spouse, Civil Partner, Service Child)
What was your address before enlisting?

Street Address

Street Address Line 2

CityCounty

Post Code
Service or Personnel number:
Enlistment date:

DayMonthYear
Date
Discharge date: (if applicable)

DayMonthYear
Date

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

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

NO:YES:
If yes, please enter details from your EHIC or PRC below:
Country Code:
Read more about using the NHS when you visit or move to England at NHS.uk.
Name

First NameLast Name
Date of Birth

DayMonthYear
Date
Personal Identification Number
Identification number of the institution
Identification number of the card
Expiry Date

DayMonthYear
Date
PRC Validity period from

DayMonthYear
Date
To

DayMonthYear
Date
Do you have an S1 form? (e.g. you are retiring to the UK or you have been posted here by your employers for work or you live in the UK but work in another EEA member state)

Yes, I will provide an S1 form
SUPPLEMENTARY QUESTIONS QUESTIONS - These questions and the patient declaration are optional and your answers will not affect your entitlement to register or receive services from your GP.

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 practiceI 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 requestedI 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.
Signature

Clear
Date:

DayMonthYear
Date
Signed (patient)

Clear
Print name:

Print name of signature:
Sign on behalf of

Clear

Your Summary Care Record

A Summary Care Record (SCR) is an electronic medical record accessible to anyone in the NHS involved in your care. This means vital information about illness, allergies and reactions to medicine will be quickly available to anyone treating you. Not having an SCR means your record would only be available on request and key information would not be easily available to those treating you. Search 'SCR' at digital.nhs.uk for full details.
Would you like a Summary Care Record set up?*

I DO want a Summary Care Record created and my records easily accessible to those treating me.I DO NOT want a Summary Care Record created.
Postcode:
Organ donation in the UK

Organ donation in England has changed to an opt-out system.

It's still for you to decide whether or not you want to become an organ donor.

Find out more at organdonation.nhs.uk

Online Services and Identity Verification
Would you like to have online access to your medicals records, prescriptions etc?*

YesNo
Are you able to confirm your identity online? This means having photo identification such as a passport or driving license with you, and the ability to take and upload a photo and video.*

YesNo
Without verifying your identity, we can't grant access to online services through this form.

Please complete and submit your application.

To sign up for online services, you'll need to visit with some photo ID to get be granted access.
You can still complete your registration through this form.

We'll contact you to arrange an ID check.

Identity Verification
Please upload picture of your photographic ID. This can be a passport, driving license or other official document.

Cancelof
To verify your identity, please write the verification code below on a piece of paper, and then upload a photo of you holding it. Both the code and your face must be clearly visible. This must be a new photo of you holding the piece paper. We will not accept an existing photo with the code typed or added over it.

Cancelof
This is your unique identity verification code.

Your Declaration*

I confirm the information provided is true to the best of my knowledge
Signature*

Clear
Name

First NameLast Name
Date

DayMonthYear
Date
Our Patient Participation Group

We are committed to improving the services we provide and our Patient Participation Group (PPG) is a great way for us to do that.The PPG acts as an advisory body to the practice, offering suggestions and ideas, asking important questions and championing the views of patients.The group meets regularly throughout the year, with meetings providing a chance for practice staff to share their plans and gather patients’ opinions, and for patients to raise issues or concerns.
Would you like to find out more about joining our PPG?

Yes
How did you hear about us?
What prompted you to join our Practice?

Personal recommendationFound us on GoogleSaw a Facebook or Twitter postFound us on the NHS website
Should be Empty:

Your Summary Care Record

Online Services and Identity Verification

Choose your Online Services

Online Access to Your Health Record

Forgotten history

Abnormal results or bad news

Choosing to share your information with someone

Coercion

Misunderstood information

Information about someone else

Identity Verification

Our Patient Participation Group

How did you hear about us?