New Patient Registration (Over 16 - Adults)

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Patient's Details

Information we need to register you with the practice
Please note all fields marked with a * are mandatory for your registration

We do double check address details when registering patients to see if you are within our catchment area. If we notice you are outside of our catchment area, we will contact you to review and agree to the out of area policy before registering you. Failure to accept the terms within 72 hours of us contacting you means your registration will be automatically rejected. Review the out-of-area policy here

if known

You do not have to provide your NHS number, but providing your NHS number can help us locate you easier on the system and prevent delays. If you don't know your NHS number; you can locate it here

You do not have to provide a copy of your ID to register with us, but sometimes we cannot find you on NHS spine. Uploading your ID now could help us find you on the NHS spine, which hopefully should prevent a delay in registering you.

if you have a double-barrelled name, or more than one surname, please include all.
We need to know a male / female gender to register you with us
Unfortunately, the system the NHS uses can only accept a male or female gender on registration, but we can make it clear on your notes your preferred gender as an alert.
if your current gender is different to the gender you were assigned at birth, we need to know what gender you were assigned at birth for the RECALL of important NHS screening opportunities
if you currently are homeless or have no fixed address, please continue to register with us, but for address and postcode sections below, please type "no fixed address" into each field
Goldsmith Students - Please ensure you include a ROOM NUMBER, otherwise there will be a delay in registering you.
UK mobile / number only
nominate a pharmacy means we can send any prescriptions directly to the pharmacy without you needing to come to the surgery
include the full address and post code of your chosen pharmacy
We need to know this, so we can look out and link your child(ren)'s registration to your records

PLEASE NOTE: if you are out of the practice catchment area and trying to register with a child/ren under 6 years old, both your and their registration may be rejected *subject to assessment, as this is against our out-of-area policy. Please register with a GP practice closer to your home address, and whose catchment area you live.

Access to our services
Ethnicity & Religion
  
Next of Kin / Emergency Contact
 

It is your responsbility to ensure that the details for your Next of Kin (NOK) or emergency contact are kept up-to-date. You can do this anytime by submitting an admin eConsult or at your next appointment.

Allergies
Previous Details

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

Please include postcode, if you have never lived in the UK, type "never lived in UK before"
if you have never had a GP before, type "never had a GP in the UK before"
If you are from abroad
Please use this date format: DD/MM/YYYY
If you are returning from abroad

Previously been registered with the NHS in the UK

Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Were you ever registered with an Armed Forces and / or been registered with a Ministry of Defence GP in the UK?

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 charities services

Supplementary Questions - If you are not a resident in the UK, but visiting or moving to the UK

These are supplementary questions and your answers will not affect your registration with us

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 at reception. Alternatively for more information go to www.nhs.uk/nhs-services/visiting-or-moving-to-england

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.

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.

A parent/guardian should complete the form on behalf of a child under 16.

European Economic Area (EEA) Country

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.

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

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

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.

Please enter the details from your EHIC or PRC below.

 
S1 Form

Please give your S1 form to the practice staff or scan the document below (note: we will need to see the original form, so please bring this to the practice as soon as possible)

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

A carer is anyone, including children and adults who looks after a family member, partner, or friend who needs help because of their illness, frailty, disability, a mental health problem or an addiction and cannot cope without their support.

If a company of organisation, please indicate which above.
 
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Lifestyle
CM or Foot' Inches''
Kg or Ibs or Stones & lbs
for free help, support and advice, please visit www.smokefreelewisham.co.uk
Your Personal Alcohol Consumption

alcohol consumption Image 1 unit

Audit Score Result

You have a score of 

If you are drinking less than 14 units of alcohol per week, then your drinking is within the UK Chief Medical Officers' low risk drinking guidelines.

But if you are drinking regularly at or above the low risk guidelines of 14 units a week, or, you are drinking six or more units - if you are female - or eight or more units - if you are male - in one single session (binge drinking), please consider the increased serious risks to your health being caused by your current drinking pattern.

 
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Medical History
Please include dates.
Please include dates.
Please include dates, and which family member
include dosage, and frequency and what it is for

Over 75 years old?

The Department of Health has advised that all patients of 75years and older have a named and accountable GP to oversee their care. Please ask the name of the GP assigned to oversee your care. Please note this does not prevent you from seeing the GP of your choice.

Immunisation History
Please include dates.
For Women and Persons with a cervix

Note: A person with a cervix aged 25-64yrs is eligible for a FREE smear test, regardless of sexual orientation and activity.

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

If you have stated that you would like a FREE smear test or want to discuss it further with a nurse; once you are registered with us, we will contact you to book your appointment if you are due, or alternatively once you receive the "welcome" text, please call and book an appointment with a female practice nurse on 020 3474 6730. 

We like to know if you have ever received the HPV vaccine

 
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Screening

At Amersham Vale Practice, we encourage all new patients to be tested for HIV, Hepatitis B (Hep B), and Hepatitis A (Hep A)

This would be performed by having a blood test. It's free!

Would you like to have a:

NHS Summary Care Records

Summary Care Record (SCR)

Please read this section very carefully before selecting your choice below

These are strict laws and regulations to ensure that your health records are kept confidential and can only be accessed by health professionals directly involved in your care. There is some sharing of information as detailed below. You can opt out of any of these at any time if you wish.

If you are registered with a GP practice in England you will have a Summary Care Record (SCR), unless you have previously chosen not to have one. It includes important information about your health, such as;

  • Medicines you are taking
  • Allergies you suffer from
  • Any bad reactions to medicines

Below are also included (if available) in the "additional information" part of your Summary Care Record to enhance the care you receive:

  • Your illnesses and health problems
  • Operations and vaccinations you have had in the past
  • How you would like to be treated - such as where you would prefer to receive care
  • What support you might need
  • Who should be contacted for more information about you

The Summary Care Record (SCR) system is designed to help both your GP and any emergency staff you contact when the surgery is closed to treat your health needs more efficiently.  NHS Summary Care Records (SCR)

Your information will be shared between your GP practice, our local hospital and Out Of Hours service. This will enable your GP surgery to access results and any visits you have at the hospital quickly and efficiently, but it also means that if you have an emergency and contact the Out Of Hours service or visit A&E they will have access to your current medications as well as allergies and are better able to treat you.

Please see CLICK HERE for more information about SCR from NHS Digital

NHS Organ Donor registration

For more information on organ donation please visit: www.organdonation.nhs.uk

NHS Blood Donor registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323

What happens to my information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.

Add today's date
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Please ignore this part, unless you get an error message on trying to submit this form 

If you receive an error message on submitting this form - firstly we like to apologise for this inconvenience, our website team is looking into this.

Please click here for an alternative version of the online registration form to complete.

Thank you

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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