NHS

Family doctor services registrationGMSI

Please complete in BLOCK CAPITALS and tick

Please help us trace your previous medical records by providing the following information Your previous address in UKName of previous GP practice while at that 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

Were you ever registered with an Armed Forces GP Please indicate if you have served in the UK Armed Forces and/or been registered with Ministry of Defence GP in the Regular Address before enlisting:

Family Member Opouse, Civil Partner, Service Child)

of applicable) Discharge date: 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

If you need your doctor to dispense medicines and appliances* live more than 1.6km in a straight line from the nearest chemist would have serious difficulty in getting them from a chemist

*Not all doctors. are authorised to dispense medicines

Signature on behalf of patient

What is your ethnic group? Please tick one bow that best describes your ethnic group or background from the options below:

White:Britishleish Traveller Any other white background (please write in Mixed:White and Black Caribõean Any other Mixed oxground (please write in): Asian or Asian British:IndianPakistani Any other Asian background (please write in): Hack or Black British:African Caribibean Any other Black background (please write in) Chinese Other ethik groupFilipino Any other ethick group (please write in) Not stated: Not Stated should be used where the PERSON has been given the opportunity to state their ITHNC CATEGORY but chose not to

GMS Family Docter Services Registration - Tearofined1

Family doctor services registration

To be completed by the GP Practice

Thave accepted this patient for general medical services on behalf of the practice

- will dispense medicines/appliances to this patient subject to NHS England approval.

declare to the best of my belief this information is correct

SUPPLEMENTARY QUESTIONS These questions and the patient declaration are optional and your answerswill not affect your entitlement to register or receive services from your GP. PATIENT DECLARATION for all patients who are not ordinarily resident in the UK Amybody in England can register with a of 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 3 practice. Being ordinarily resident broedly means living Nawfully in the UK on 4 properly settled basis for the time being In most cases,nationals of countries outside the turepean Economic Area musit also have the status of indefinite leave to remain' in the UK. Some services, such as diagnestic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are net ordinarily resident here are exempt from all treatment charges More information on residence, exemptions and. paying for senvices, can be found in the and Migrant patient Jeaflet available from your. GP practice. Yeu may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the 3 practice, otherwise you may be charged for your treatment. Even if you have to pay for 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. hospital) and NHS Digital, for the purposes of validation, invoicing and cost recovery You may be contacted on behalf of the NHS to confiem any details you have provided. Please tick one of the following bowes

a)understand that may need to pay for NHS treatment outside of the GP practice b)undenstand lhave valid exemption from paying for treatment outside of the 5 practice. This includes for esample, in EHIC, or payment of the Immigration Health Charge ("the Surcharge") when accompanied by . valid visa. can provide documents to support this when requested odo not know my chargeable status Ideclare that the information - give on this form is correct and complete. Tundentand that ditis not correct appropriate action may be taken against me A parent/guardian should complete the form on behalf of child under 16.

Complete this section if you live in an tu country, or have moved to the UK to study or retire, or if you live in the UX but work in another tEA member state. De not complete this section if you have an EHIC issued by the UK.

Do you have a non-UK EHIC or PRC?

if yes, please enter details from your EHIC or PRC below:

# you are visting from another IEA country and do not hold current DHC (or Provisional Replacement Certificate you may be billed for the cost of any received outside of the GP practice including at hospital

Please tickif you have an $1 (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 $1 form to the practice staff.

How will your 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 Chospitald and NHS Digital solely for the purposes of cost recovery. Your cinical data will not be shared in the cost recovery process Your EHIC PRC or si information will be shared with Business Service Authority for the purpose of recovering your NHS costs from your home country

GMS Fambly Docter Services Tearofined 2