Temp Patient Registration Form (GMS3) VER23

Fields marked "REQUIRED" are compulsory. You should only send this form if you are sure that you are eligible to join this practice.

Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 01/12/2023

Patient's Details

Title *

SURNAME *

FIRST NAME(S) *

PREVIOUS SURNAME *

DATE OF BIRTH *

NHS NUMBER

How to find your NHS number

https://www.nhs.uk/find-nhs-number/

SEX *

FULL Home ADDRESS *

POSTCODE *

TELEPHONE *

EMAIL ADDRESS *

FULL Temporary ADDRESS

FULL Temporary ADDRESS POST CODE

Your Current GP SURGERY

PATIENT AGREEMENT The Harefield Practice

DISCLOSURE I THE PATIENT NAMED BELOW AGREE TO DISCLOSE ALL MATERIAL FACTS REGARDING MY HEALTH TO MY GENERAL PRACTITIONER AND HIS/HER CLINICAL STAFF. WE THE.PRACTICE DECLARE THAT WE SHALL NOT DISCLOSE ANY INFORMATION REGARDING THE PATIENT WITHOUT WRITTEN CONSENT. CONFIDENTIALITY WE THE PRACTICE DECLARE THAT WE SHALL HOLD CONFIDENTIAL ALL MATTERS PERTAINING TO THE PATIENT AND NOT RELEASE SUCH INFORMATION WITHOUT THE PATIENT'S WRITTEN CONSENT. *

I understand and agree

APPOINTMENTS I AGREE TO TRY TO ATTEND ON TIME FOR ALL APPOINTMENTS THAT 1 BOOK WITH THE PRACTICE AND CANCEL IN ADVANCE ANY APPOINTMENT THAT I CANNOT ATTEND. I ACKNOWLEDGE THAT SHOULD I ARRIVE LATE FOR AN APPOINTMENT I I MAY BE ASKED TO REBOOK FOR ANOTHER TIME. WE WILL TRY TO SEE YOU AT YOUR APPOINTMENT TIME BUT MAY ASK YOU TO COME BACK FOR ANOTHER APPOINTMENT IF YOUR PROBLEM TAKES LONGER THAN THE TIME YOU HAVE BOOKED. IF YOU HAVE MORE THAN ONE PROBLEM TO DISCUSS YOU CAN ASK FOR A DOUBLE APPOINTMENT WHEN YOU CONTACT RECEPTION *

I understand and agree

HOME VISITS I SHALL ONLY REQUEST A HOME VISIT FOM THE PRACTICE UNDER CIRCUMSTANCES WHERE I CANNOT PHYSICALLY ATTEND AT THE PRACTICE; I WILL ENDEAVOUR TO MAKE THIS REQUEST NO LATER THAN 11.00AM. *

I understand and agree

. POLICY ON SEEING MINORS ALL CHILDREN UNDER THE AGE OF 12 MUST BE ACCOMPANIED BY AN ADULT THROUGHOUT THE CONSULTATION AND EXAMINATION. YOUNG PEOPLE BETWEEN 12 AND 14 CAN CONSULT ALONE BUT MUST ATTEND THE SURGERY ACCOMPANIED BY A RESPONSIBLE ADULT WHOSE PERMISSION AND COOPERATION WILL BE SOUGHT. 14-16 YEAR OLDS MAY ATTEND UNACCOMPANIED AND CONSULT ALONE PROVIDED THAT THE DOCTOR ASSESSES THEM TO BE COMPETENT. OUR CONFIDENTIALITY POLICY GIVES ANYONE OVER THE AGE OF 14 THE RIGHTS TO ONLY HAVE TEST RESULTS GIVEN TO THEM, THE PATIENT, AND RESULTS WILL ONLY BE GIVEN TO THE PARENT IF IT IS CLEARLY WRITTEN IN THE PATIENT NOTES THAT PERMISSION HAS BEEN GIVEN FOR THAT EPISODE OF CARE *

I understand and agree

MOBILE PHONES I AGREE TO SWITCH OFF MY MOBILE PHONE BEFORE ENTERING THE PRACTICE AND TO KEEP IT SWITCHED OFF AT ALL TIMES WHILE I AM WITHIN THE PRACTICE BUILDING. I AGREE TO SWITCH IT OFF IMMEDIATELY SHOULD IT RING WHILE LAM WITHIN THE BUILDING *

I understand and agree

TREATMENT OF STAFF I AGREE WITH THE POLICY OF ZERO TOLERANCE OF ABUSE TOWARDS ALL NHS STAFF. I AGREE NOT TO BEHAVE IN AN ABUSIVE, THREATENING OR OTHERWISE AGGRESSIVE MANNER WITH ANY MEMBER OF THE PRACTICE STAFF. L ACKNOWLEDGE THE RIGHT OF THE PRACTICE TO REMOVE ME FROM THEIR LIST WITHOUT APPEAL SHOULD I BEHAVE IN A MANNER PROHIBITED. ALL THE STAFF AND DOCTORS AGREE TO BEHAVE IN A POLITE AND PROFESSIONAL MANNER. *

I understand and agree

COMPLALNTS IF I AM DISSATISFIED WITH THE SERVICE I RECEIVE FORM THE PRACTICE I WILL COMPLAIN IN WRITING TO THE PRACTICE MANAGER. THE PRACTICE AGREES TO TAKE ALL COMPLAINTS SERIOUSLY AND WILL REPLY IN WRITING WITHIN 14 DAYS. *

I understand and agree

WE ARE OFTEN ASKED TO WRITE LETTERS AND COMPLETE FORMS ON BEHALF OF PATIENTS. THIS ISN'T COVERED UNDER THE NHS. PAYMENTS ARE TO BE MADE IN ADVANCE BEFORE THE WORK CAN BE COMPLETED. PLEASE CONTACT THE SURGERY FOR AN UP TO DATE PRICE IF NECESSARY BEFORE LEAVING YOUR REQUEST. • PRIVATE SICK NOTES • PRIVATE PRESCRIPTIONS FOR TRAVELLING ABROAD • HOLIDAY VACCINATION CERTIFICATE • PRIVATE MEDICAL CERTIFICATE • SICKNESS/ACCIDENT BENEFIT FORM • FIT TO TRAVEL • FREEDOM FROM INFECTION CERTIFICATE • HOLIDAY CANCELLATION FORM • MEDICALS • PRIVATE VACCINATIONS *

I understand and agree

Temp PATIENT QUESTIONNAIRE

If you are from abroad

DATE OF ENTRY TO THE UK

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.

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:

Regular

Reservist

Veteran

Family Member (Spouse, Civil Partner, Service Child)

ENLISTMENT DATE

DISCHARGE DATE (IF APPLICABLE)

ADDRESS BEFORE ENLISTING

SERVICE OR PERSONNEL NUMBER

Complete Registration

SIGNATURE *

Signature of patient

Signature on behalf of patient

SIGNED (Your Name) *

DATE *

SUPPLEMENTARY QUESTIONS | 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 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.

Are you a parent or guardian, filling out this form on behalf of a child under 16?

SIGNED (You Name)

Date

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 the GP practice, including at hospital).

DO YOU HAVE A NON-UK EHIC OR PRC?

Yes No

IF YES, PLEASE ENTER DETAILS FROM YOUR EHIC OR PRC BELOW:

COUNTRY CODE:

SURNAME

GIVEN NAMES:

DATE OF BIRTH

PERSONAL IDENTIFICATION NUMBER:

IDENTIFICATION NUMBER OF THE INSTITUTION:

IDENTIFICATION NUMBER OF THE CARD:

EXPIRY DATE:

PRC VALIDITY PERIOD

A) FROM:

B) TO:

PLEASE TICK IF YOU HAVE AN S1 (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.

I have an S1 form

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.

Do you understand the above and agree to the above? *

I understand the above and agree to the above

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Temp Patient Registration Form (GMS3) VER23

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