Family doctor services registration GMS1

Patient’s details Please complete in BLOCK CAPITALS and tick as appropriate

Surname
Mr Mrs Miss Ms

Date of birth First names

NHS Previous surname/s

No.
Town and country
Male Female of birth
Home address

Postcode Telephone number

Please help us trace your previous medical records by providing the following information
Your previous address in UK Name of previous doctor while at that address

Address of previous doctor

If you are from abroad

Your first UK address where registered with a GP

If previously resident in UK, Date you first came

date of leaving to live in UK

If you are returning from the Armed Forces

Address before enlisting

Service or Enlistment
Personnel number date

If you are registering a child under 5

I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance

If you need your doctor to dispense medicines and appliances* *Not all doctors are
authorised to
I live more than 1 mile in a straight line from the nearest chemist dispense medicines
I would have serious difficulty in getting them from a chemist

Signature of Patient Signature on behalf of patient Date________/_________/_________

NHS Organ Donor registration

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation
after my death. Please tick the boxes that apply.
Any of my organs and tissue or
Kidneys Heart Liver Corneas Lungs Pancreas Any part of my body

Signature confirming my agreement to organ/tissue donation Date ________/________/________

For more information, please ask at reception for an information leaflet or visit the website
www.uktransplant.org.uk, or call 0300 123 23 23.

NHS Blood Donor registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.
Tick here if you have given blood in the last 3 years
Signature confirming consent to inclusion on the NHS Blood Donor Register Date ________/________/________

For more information, please ask for the leaflet on joining the NHS Blood Donor Register
My preferred address for donation is: (only if different from above, e.g. your place of work)
Postcode:

HA use only Patient registered for GMS CHS Dispensing Rural Practice

042017_003 Product Code: GMS1

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 Family doctor services registration GMS1

To be completed by the doctor

Doctors Name HA Code

I have accepted this patient for general medical services For the provision of contraceptive services
I have accepted this patient for general medical services on behalf of the doctor named below who is a member of this practice
Doctors Name, if different from above HA Code

I am on the HA CHS list and will provide Child Health Surveillance to this patient or
I have accepted this patient on behalf of the doctor named below, who is a member of this practice and is on the
HA CHS list and will provide Child Health Surveillance to this patient.
Doctors Name, if different from above HA Code

I will dispense medicines/appliances to this patient subject to Health Authority’s Approval

I am claiming rural practice payment for this patient.
Distance in miles between my patient’s home address and my main surgery is

I declare to the best of my belief this information is correct and I claim the Practice Stamp
appropriate payment as set out in the Statement of Fees and Allowances. An audit
trail is available at the practice for inspection by the HA’s authorised officers and
auditors appointed by the Audit Commission.

Authorised Signature

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:
a) I understand that I may need to pay for NHS treatment outside of the GP practice
b) 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
c) 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.

Signed: Date: DD MM YY

Print name:
Relationship to
patient:
On behalf of:

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 REPLACEMENT CERTIFICATE (PRC)
DETAILS and S1 FORMS
If yes, please enter details from your EHIC or
Do you have a non-UK EHIC or PRC? YES: NO:
PRC below:
Country Code:
3: Name
4: Given Names
5: Date of Birth DD MM YYYY
6: Personal Identification
If you are visiting from another EEA Number
country and do not hold a current 7: Identification number
EHIC (or Provisional Replacement of the institution
Certificate (PRC))/S1, you may be billed
for the cost of any treatment received 8: Identification number
outside of the GP practice, including of the card
at a hospital. 9: Expiry Date DD MM YYYY
PRC validity period (a) From: DD MM YYYY (b) To: DD MM YYYY
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.
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.

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