If you would like to register with the Practice please use this form.

It is important that you first check to confirm you live within our Practice Boundary before you complete this registration form. There are currently a number of housing developments being built so if you are moving into one of these and think your postcode is within our area, please Contact Reception as it can take a little while for new postcodes to be recognised. Please be aware that the Bucklers Park development on Old Wokingham Road is outside our boundary.

If you have served more than 24 hours or more as reserve or regular in the Armed Forces, please complete the Veteran Details section. If you are a Veteran, please see this Important Information.

If you are registering a child under 14 years old please complete our Child Registration Form. Please note that when you bring in your child’s ID to complete the registration process, please also bring with you your child’s Red Book so that we can photocopy their immunisation history.

In order to complete the registration process, you will then need to bring into the Practice: Photo ID, proof of address and your child’s red immunisation book (if applicable). Please be aware that it may take up to 2 weeks for us to complete the registration process so please help us to help you by bringing in your ID as soon as possible.

Please also help us by bringing in ID, proof of address and your child’s Red Book (if applicable) Mondays-Fridays between 1.30pm – 5.30pm as mornings and the end of our working day are our busiest times.

Thank you.

Temporary Patients

If you are staying temporarily within our boundary area and need to see a GP or nurse, please contact reception to discuss your needs and they will tell you what you need to do to register as a temporary patient. Practice boundaries often cross over, so the general rule is that if you are staying with someone (friend/family/relative) we would normally expect you to be seen by the practice they are registered with. If you are here for work/visiting and staying in a hotel/guest house etc. you can ask to be seen at any GP practice that covers that area. Reception can be contacted on 01344 773 418 8:00am-6:30pm Monday to Friday. If we are closed please call NHS 111 for advice and assistance.

New Patient Registration

If you are human, leave this field blank.

Patient's Details

Title *

Mr

Mrs

Miss

Ms

Other

Please specify:

Surname: *

Previous Surnames:

First Name(s) *

Date of Birth: *

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

Gender *

Male

Female

Indeterminate

NHS Number:

Town and Country of birth: *

Home Address: *

Postcode: *

Email Address: *

Any responses we send will go to this email address.

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

Can we contact you by text?

Yes

No

Can we contact you by email?

Yes

No

Ethnicity

Please specify the ethnic group you consider you belong to:

White British

White Irish

Black Caribbean

Black African

Black Caribbean and White

Black African and White

Indian

Pakistani

Bangladeshi

I do not wish to state

Other ethnic group

Please state:

Do you speak English?

Yes

No

Do you read English?

Yes

No

First Language:

Next of Kin Details

Full Name:

Relationship to patient:

Contact Number:

Email Address:

Address (including postcode):

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

Registering with the NHS for the first time in the UK

Date you came to live in the UK:

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

If you are returning from abroad

Previously been registered with the NHS 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

I am not ordinarily a resident in the UK

Ordinarily Resident

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. Alternatively for more information go to www.nhs.uk/visitingengland.

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 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

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.

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

Please enter the details from your EHIC or PRC below.

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.

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

Veteran Details

Are you a veteran?

Yes

No

Veteran Type:

Army

Royal Air Force

Royal Navy

Royal Marine