New Patient Registration Form

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New Patient Registration Form

Before you complete this form, please ensure you have to hand:

  1. Name and address of your previous GP practice (if you have previously registered with a GP Practice in the UK)
  2. Your NHS number (if you have previously registered with a GP Practice in the UK)
  3. Your Photo ID, such as a driving license, identity card or passport (if you have one)
Patient's Details

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

Ethnicity & Religion
Communication and Access Needs

Are you an ‘Assistance Dog’ user?

The Equality and Human Rights Commission define assistance dogs as dogs trained to help people with hearing difficulties, epilepsy, diabetes, physical mobility problems and more.

Emergency Contact
Previous Details
Please include postcode
Please indicate if you have ever served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas:
Allergies
If you are from abroad
Please use this date format: DD/MM/YYYY
If you are returning from abroad

Previously been registered with the NHS in the UK

Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Supplementary Questions

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 at reception. Alternatively for more information go to www.nhs.uk/nhs-services/visiting-or-moving-to-england

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.

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.

European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea

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

Book appointments and order repeat prescriptions online. 


You can book appointments at the practice, request repeat prescriptions for any medications you take regularly and view your medical record securely online using Patient Access.

Being able to see your record online might help you to manage your medical conditions. It also means that you can access it from anywhere in the world should you require medical treatment on holiday. 

The service is open 24/7/365 and can be accessed from your home PC, Tablet or Mobile at https://www.patientaccess.com/ or with the Patient Access app for Apple and Android devices.

Before you apply for online access to your record, please consider the following situations:

Forgotten history
There may be something you have forgotten about in your record that you might find upsetting.

Choosing to share your information with someone
It’s up to you whether or not you share your information with others – perhaps family members or carers. It’s your choice, but also your responsibility to keep the information safe and secure. Should you share your login credentials, they would be able to book appointments or order repeat prescriptions. They may be able to see your record to help with your healthcare if you wish.

Using your record to complete forms
The information that you can see online may be misleading if you rely on it alone to complete insurance, employment or legal reports or forms.

Important information for patients viewing test results online
If you have been given access to view your test results online these will become available after one of the doctors has viewed and commented on them. Some results arrive in the practice with a comment from the lab of “Abnormal” or will show with a little red marker outside the normal range. It is important to look at the comment of the doctor who has viewed the result rather than this lab marker!

Abnormal results or bad news
With online records access you may see something that you find upsetting. This may occur before you have spoken to your doctor or while the surgery is closed and you cannot contact us. If this happens please contact us as soon as possible. The practice may hide parts of your record so that certain details are not displayed online. For example, we may do this with test results that you might find worrying until we have had an opportunity to discuss the information with you.

Coercion
If you think you may be pressured into revealing details from your patient record to someone else against your will, it is best that you do not register for access at this time.

Information about someone else
If you spot something in the record that is not about you or notice any other errors, please log out of the system and contact the practice as soon as possible.

Corrections
If you feel that any information is incorrect or that your record is missing information, we can add amendments to your record, but we cannot delete or alter any historical information.

The marker which says “normal” may not be appropriate for you
In some situations the lab will view a result as normal when it is not correct for you. One example of this would be a patient on treatment for gout. The normal range for the test goes up to a value of 450, but if you are on treatment we target a value of below 300.

The marker which says “abnormal” may not be appropriate for you
The lab marker is based on a sample, if your result is in the same range as 95% of normal tests it will be marked as normal – so 5% of “normal” tests will be marked as abnormal.

Misunderstood information
Your medical record is designed to be used by clinical professionals to ensure that you receive the best possible care. Some of the information within your medical record may be highly technical, written by specialists and not easily understood. If you require further clarification, please ask your GP when you next speak to them.

 
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Lifestyle
Your Personal Alcohol Consumption

alcohol consumption Image 1 unit

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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Adult Females
Please use this date format: DD/MM/YYYY.
Immunisation History
Please include dates.
Medical History
Please include dates.
Please include dates.
Please include dates.

Over 75 years old?

The Department of Health has advised that all patients of 75years and older have a named and accountable GP to oversee their care. Please ask the name of the GP assigned to oversee your care. Please note this does not prevent you from seeing the GP of your choice.

Patient Participation Group (PPG)

The Practice is committed to improving the services we provide to our patients. To do this, it is vital that we hear from our patients about their experiences, views, and ideas for making our services better. By expressing your interest, you will be helping us plan ways of involving patients to help us improve our services in a way that suits you. It will also mean that we can keep you informed of opportunities to give your views and up to date with developments within the Practice.


If you are interested in getting involved in the PPG, please tick yes in the box below and ask the Receptionist on-duty for the PPG joining form.

Other information
 
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NHS Organ Donor registration

For more information on organ donation please visit: www.organdonation.nhs.uk

NHS Blood Donor registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323

What happens to my information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.

NHS Research & Planning 

National Initiative 

Your health and adult social care information supports your individual care. It also helps the NHS to research, plan and improve health and care services in England. Unless you have chosen to opt out, your confidential patient information can be used for research and planning.

To opt out of NHS Research and Planning, go to; www.nhs.uk/your-nhs-data-matters

You can opt out online by providing your address and NHS number.  

Health Information Exchange


Local Initiative

We're joining up your health and care information to improve the local services you recieve. 

What does this mean for you?
Health and care professionals invovled in your care will be able to see your information and make quicker and safer decisions about your care. 

For more information, including how to opt-out
click here

Summary Care Record

National Initiative

If you have a Summary Care Record your health care providers can view your medication, bad reactions to medications and allergy information when treating you in an emergency or when your practice is closed. 
Patient declaration

In accordance to the NHS Constitution, the first duty of Swiss Cottage Surgery is to provide a comprehensive service, available to all irrespective of gender, race, disability, age, sexual orientation, religion, belief, gender reassignment, pregnancy and maternity or marital or civil partnership status.

To help render this essential service, the Constitution makes certain provisions of which the more important are stated overleaf. It is important for you to know and understand those provisions.
For further information on the NHS Constitution, please visit: https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england

YOU SHOULD READ CAREFULLY THIS STATEMENT AND THEN SIGN YOUR NAME TO THE DECLARATION BELOW.

I hereby declare and confirm that the personal details and home address that I have provided are complete, accurate and free of error. I bear the responsibility for the correctness of these details.
As stated in the NHS Constitution, I must provide accurate information about my health, condition and status. I therefore acknowledge that if the home address that I have provided is found and proven to be inaccurate I will be de-registered from Swiss Cottage Surgery, as residing outside the Practice catchment (boundary) area. It will be my responsibility to then find and register with a new GP Practice closer to my home address. I understand that I may be able to re-register at Swiss Cottage Surgery under the Out of Area scheme, at the discretion of the Practice.

I understand that it is my responsibility to inform Swiss Cottage Surgery if any of the details I have provided change as soon as possible.

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 (opens in a new tab) to discover how we protect and manage your submitted data.

 
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