Muswell Hill Practice New Patient Registration Form (GMS1) + Health Questionnaire

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 will NOT automatically register you with the surgery. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register. Before You Register This is a long form, it may be useful to have to hand: Your NHS Number (if you have one), the address of your previous doctors surgery (if you have one), the date you arrived in the UK (if you weren’t born in the UK), your EHIC Card or PRC (If you do not ordinarily live in the UK and have one of these), your Armed Forces personnel number and start date (If you served in the Armed Forces). Please note: You can only be registered with one GP practice. If you register with us, you will be de-registered from your current GP practice. Please allow 10 working days for your registration form to be processed.

Last Updated: 18/04/2024

Initial Questions

Are you completing this form on behalf of... *

Myself

Someone else (State your relation to them)

Today's Date *

If someone else, state your relation to them:

Your Details

Please help us trace the patients previous medical records by providing the following

Ethnicity and languages

Please select your ethnic group *

What is your main language *

Other spoken languages

Do you need an interpreter?

Yes No

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

Your previous address in UK, if none please write n/a *

Name of previous GP while at previous address, if none please write n/a *

Address of that Doctor

Contact with the Surgery

Important questions to help you use our services

Do you want to receive text reminders to mobile telephones about appointments and other clinical services? *

Yes No

If yes, please provide a contact email address.

If you are from abroad

Your first UK address where registered with a GP

If previously resident in UK, date of leaving

Date you first came to live in UK (DD/MM/YYYY) *

If you are returning from the armed forces

Address before enlisting

LEAVING DATE

Service/Personnel No.

Enlistment date

Next of Kin

Please give us the details of who to contact in case of emergency, this can be a friend or family member.

Title: *

Name *

Contact number *

Relationship to you *

Carer

A carer is someone who looks after an adult or a child with a chronic disease, mental health problem, learning or physical disability, sensory impairment or who are otherwise unable to care for themselves (i.e. this does not include a parent of a normal child)

Are you a carer? *

Yes No

If Yes, provide the details of the person you care for (Name and Relationship)

Do you have a carer? *

Yes No

IF Yes, provide their details, (Name of the carer, relationship and mobile contact details)

Communication Support

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:

Name:

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.

How will your EHIC/PRC/S1 data be used?

I have read and understood

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?

Name parent or guardian

Relationship to patient:

Signed

Date

Height and Weight

Height (Please include Units)) *

Weight (Please include Units) *

Blood Pressure (if you cannot take your own blood pressure, please come into the surgery and speak to reception)

Smoking

Do you smoke? *

Yes No

Have you ever smoked? *

Yes

If Yes, How many cigarettes/tabacco do you smoke a day?

Would you like help with smoking cessation? *

Yes No

Alcohol

The questions below refer to a standard drink which means either: half a pint of ordinary beer/lager/cider; a single measure of spirits; a small glass of wine; or a small glass of sherry. Each answer is scored by a number of points, found in the brackets at the end of the answer. Please add up your points as you answer the questions, you will be asked for this number at the end of the section.

How often do you have a drink containing alcohol? *

IF you do drink alcohol, how many standard units do you have on a typical day? *

How often have you had 6 or more units if female, 8 or more if male, on a single occasion in the last year? *

Please add up your points from your answers to questions 1-3 (found in the brackets) *

How often during the last year have you found that you were not able to stop drinking once you had started? *

How often during the last year have you failed to do what was normally expected of you because of your drinking? *

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy session of drinking? *

How often during the last year have you had a feeling of guilt or remorse after drinking? *

How often during the last year have you been unable to remember what happened the night before because you had been drinking? *

Have you or somebody else been injured as a result of your drinking? *

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? *

Please add up your points from your answers to questions 5-11 (found in the brackets) *

Occupation

WHAT IS YOUR CURRENT OCCUPATION? *

Allergies

Please tell us about any allergies or any adverse reactions to medication prescribed in the past:

Are you allergic to anything? *

Yes No

Please list if any

Medication

If you are on 2 or more medications (not including the contraceptive pill), please list them below:

Electronic Prescriptions (EPS)

Prescriptions can now be sent direct to a pharmacy of your choice. This is called nomination. This can be set up with a pharmacy near to where you live, work or shop. You no longer have to visit the practice to pick up your paper prescriptions, they can be sent electronically to the pharmacy you choose saving you time. All you need to do is fill in the information below and the practice can set this up for you. Alternatively, you can ask your pharmacist to set this up. You can change or cancel your nominated pharmacy at any time. Please ask at reception if you would like any more information on EPS.

Please let us know the address of your pharmacy of choice *

Patient Agreement

Thank you for registering at The Muswell Hill Practice. We welcome you here and aim to provide a high standard of service to all our patients. In order for us to maximise the service we are able to give, we request that patients agree to the following requests. Patients will be warned should this happen and it may result in a removal from the practice list.

Summary Care Record Opt Out Form

A Summary Care Record is a way of telling health and care staff important information about a person. For people with a learning disability, autism or both a doctor might ask if they can add some additional information to the summary care record. This will mean if a person needs treatment by other services like emergency or urgent care they will have more information about them. If you choose to opt out, NHS healthcare staff caring for you may not be aware of your current medications, allergies you suffer from and any bad reactions to medicines you have had, in order to treat you safely in an emergency. Your records will stay as they are now with information being shared by letter, email, or phone. If you have any questions, or if you want to discuss your choices, please contact the practice. It tells staff caring for someone about their medicines and allergies. This means they can look after the person if they are not at their usual doctor’s surgery.

Please let us know your Summary Care Record preferences: *

YES, I would like a summary care record

NO, I do not want to have a summary care record

If you are filling out this form on behalf of another person or a child, please fill your name and your relationship to the patient below:

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Muswell Hill Practice New Patient Registration Form (GMS1) + Health Questionnaire

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