New Patient Registration

Patient's Agreement Policy

On joining the Tollgate Practice I have read and agree with the following:

If I do not attend three (3) appointments with either a doctor, a nurse practitioner or a practice nurse without prior or sufficient notice, I will receive a warning letter. Following this letter, if I then miss one (1) more appointment I will be REMOVED from your practice list. I understand that by not turning up for appointments, I am denying other patients who are ill and need to be seen the opportunity of being offered an appointment.
I must be prepared to see the nurse practitioner instead of the doctor for minor illness, or when appropriate (please note – our nurse practitioners are skilled and are an essential part of our patient care team, helping to free up the doctors’ time for patients with more complex problems).
I understand and will not be impatient and abuse the reception staff (please note – the length of a routine appointment with the doctor is 10 minutes). If you need to discuss more than 1 problem, please ask for a double appointment (20 minutes). We try to keep to appointment times, but our clinics do sometimes overrun, please be patient.
It is with regret that we have to ask ALL patients to agree not to be abusive to any of our staff as we find this kind of behaviour is increasing. The surgery is now enforcing a ZERO TOLERANCE and therefore we will REMOVE any such patients from our practice list.

I understand and agree that I will adhere to the above policy.

Print Name: *

(Printing your name will be deemed as agreement to the above)

Date:

If you have any concerns regarding the above, please ask to speak to the Practice Manager.

Patient's Details

Text/SMS & Emails

Please specify:

You may receive information by letter and phone, however you must consent to receive information by text/SMS or email. These details will never be provided to third parties. The information sent may be about appointments, results, referrals, messages about your specific health needs (e.g. a flu vaccination reminder or a diabetic management plan) and general health information and updates that could benefit you. The responsibility for attending and cancelling appointments, collecting prescriptions and obtaining results still rests with you though. It is also your responsibility to ensure that you have the appropriate security settings on your phone, tablet and/or computer to maintain the privacy of the message.

I consent to be contacted by text *

Yes

No

I consent to be contacted by email *

Yes

No

Surname: *

Previous Surnames:

First Name(s) *

If this is a shared number or email address, I consent to my information being sent here

Printing your name will be deemed as agreement to the above

NHS Number:

Gender *

Male

Female

Indeterminate

Print Name: *

Date:

The information recorded above is accurate to the best of my knowledge & I take full responsibility to inform Tollgate Practice if my contact details change in the future.

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

What is your ethnic group? *

Which one best describes your White background? *

British

Irish

Irish Traveller or Gypsy

Any other White background

Which one best describes your Mixed background? *

White and Black Caribbean

White and Black African

White and Asian

Any other mixed background

Which one best describes your Asian or Asian British background? *

Which one best describes your Black or Black British background? *

African

Caribbean

Any other Black background

Which best describes your other ethnic group background? *

Arab

Any other ethnic group

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

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

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