New Patient Registration

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Out of Area Registration

We are now able to register appropriate patients outside of our practice area.

Patients who live within the area shown below, requiring a home visit, can be visited by a WHMC clinician as clinically indicated.
Patients living outside of this area requiring a visit would be seen by a GP from a local practice or 111 as per national protocol.
Out of Area registrations is intended to help patients to facilitate face to face appointments i.e. for those who live or work nearby.
Any patient who is out of our practice area who is likely to require home visits or has mobility issues and would struggle to come in at short notice, should register with a GP that is local to them whose catchment area they fall within.
Similarly, any patient who has needs that require a locally based teams such as district nurses, mental health teams, psychiatry, health visitors and social care should register with a local surgery within their borough as there will be issues accessing these services linked to our practice.
We will also not be a part of or have access to any integrated local multidisplinary teams or other professional networks like primary care networks outside of our area.
Finally, all out of area patients registering with us should be able to commute easily to our surgery for appointments as well as to be able to access local services including investigations and blood taking services based at local services.
In simple terms, out of area registrations are intended to facilitate face to face appointments for patients ie make it easier for patients to see a GP and not the opposite.
If a Patient inappropriately registers through the out of area scheme and the practice assess that it is clinically inappropriate for them to remain registered (ie that they fall outside the out of area policy), they will be required to register with practice a closer to them.

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Patient's Details

Information we need to register you with the practice
Please note all fields marked with a * are mandatory for your registration

Title: *

Gender: *

By supplying us with your email and mobile you agree to us contacting regarding your health

Ethnicity

Please specify the ethnic group you consider you belong to: *

Please describe in your own words your ethnic background

If English is not your first language, will you need an interpreter?:

Reasonable Adjustments

Do you have a medical condition or disability that requires any reasonable adjustments?: *

Reasonable adjustments help to ensure all patients receive equitable care by recognising and removing these barriers.

Examples include providing information in accessible formats, arranging Interpreters, & offering longer appointments

Emergency Contact

Are they your Next of Kin?:

Previous Details

Please include postcode

Are you registering for the first time in the UK? : *

Are you returning from abroad?: *

If you are from abroad

Please use this date format: DD/MM/YYYY

Refugee: *

Asylum Seeker: *

Do you require an interpreter when you see the doctor/nurse?: *

Are you returning from abroad? : *

If you are returning from abroad

Previously been registered with the NHS in the UK

Please use this date format: DD/MM/YYYY

Have you ever served in the Military

Have you ever served in the Military?: *

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:

Which of the below is applicable to you:

Footnote: 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

European Economic Area (EEA) Country

For a list of EEA countries visit the government website

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?:

Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?:

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.

Please enter the details from your EHIC or PRC below.

S1 Form

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

Are you cared for by others?: *

i.e. do you have a paid or voluntary carer (ie friend/relative) who helps you live your day to day life

Are you a carer?: *

i.e. do you look after a friend or relative who is sick or disabled or has a significant mental problem or special needs (including a parent or guardian of a child)

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Adult Females

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

Was it done at:

Have you had a hysterectomy?:

Do you still have your ovaries?:

Immunisation History

Please include dates.

Medical History

Please include dates.

Family History:

Have any close family members (parents, siblings, aunts, uncles and grandparents) suffered from any of the following illnesses, Please include dates.

HIV:All new patients above the age of 16 are eligible to have a HIV blood test. If you would like this please request a blood test form from reception

Chlamydia: If you are sexually active you can do a self-taken Chlamydia test. These are available in the toilets of the surgery and can be handed in to reception.

Lifestyle

Smoking Status: *

Your Personal Alcohol Consumption

1unitofalcohol

What does 1 unit of alcohol look like?

Cider (218ml, ABV 4.5%)
Wine (76ml, ABV 13%)
Whisky (25ml, ABV 40%)
Beer (250ml, ABV 4%)
Alcopop (220ml, ABV 4%)

If you are unsure about your alcohol consumption please visit the NHS Website

ALCOHOL UNIT ADVICE

How often did you have a drink containing alcohol in the past year?: *

How many units of alcohol did you have on a typical day when you were drinking in the past year?(NB 1U=1/2 Pint of Beer= 1 small glass of wine = 1 measure of spirits): *

How often did you have six or more drinks on one occasion in the past year?: *

Audit Score Result

you have a score of

If you are drinking less than 14 units of alcohol per week, then your drinking is within the UK Chief Medical Officers' low risk drinking guidelines.

But if you are drinking regularly at or above the low risk guidelines of 14 units a week, or, you are drinking six or more units - if you are female - or eight or more units - if you are male - in one single session (binge drinking), please consider the increased serious risks to your health being caused by your current drinking pattern.

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Patient online access

We encourage all patients to obtain online access to their records.

This will allow you to use patient apps like the NHS App which will allow you to: book appointments, make online consultations with us for simple requests using eConsults, request repeat prescriptions and look up information on your medical records like immunisations, blood test and other results with comments as well as update donation preferances.

For us to be able to enable this functionality we need to confirm your identity so please ensure you upload your photo identification and proof of address as requested at the end of this form (page 4).

Summary Care Record

Summary Care Record (SCR)

The Summary Care Record (SCR) system is designed to help both your GP and any emergency staff you contact when the surgery is closed to treat your health needs more efficiently.

Your information will be shared between your GP practice, our local hospital and Out Of Hours service. This will enable your GP surgery to access results and any visits you have at the hospital quickly and efficiently, but it also means that if you have an emergency and contact the Out Of Hours service or visit A&E they will have access to your current medications as well as allergies and are better able to treat you.

SCR Options:

If you do not return this form, a Summary Care Record will be created for you based on implied consent

NHS Organ Donor Registration

NHS Organ Donor Registration

At this stage we will be mainly noting your preferences internally. However, if contacted by the transplant service we would notify them of your choices and therefore by ticking a box you are confirming your agreement to the organ/tissue donation.

Please leave this section blank if you do not wish to register you preferences

My preferences for the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply:

NHS Blood Donor Registration

NHS Blood Donor registration

At this stage we will be mainly noting your preferences internally. However, if contacted by the blood & transplant service we would notify them of your choices and therefore by ticking a box you are confirming your agreement to the organ/tissue donation.

Please leave this section blank if you do not wish to register.

My preferences for joining the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood:

Patient Participation Group

Please tick if you are happy for the surgery to contact you about developments at the surgery and Open Patient Participation Group meetings:

You can withdraw consent in writing at any time

MORE INFOR ABOUT THE PPG

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Identification Upload

Patient Identification

To fully register you at the practice, we need Two forms of Acceptable ID (if not possible, please let us know).

We will not store these documents and we will securely delete / destroy them after our initial verification.

OPTIONAL: Photo of your face to add to your records to help us identify you (if you agree)

Acceptable Identification: Photo Driving License, Passport, Tenancy agreement, Mortgage statement, Bank statement, Utility bill (date within the past 3 months) etc.

Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx

Signature

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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New Patient Registration

We are now able to register appropriate patients outside of our practice area.

you have a score of

Summary Care Record (SCR)

Patient Identification

Privacy Consent

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