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Online New Adult Patient Registration

Dear Patient,

Please kindly take a few minutes to fully complete this form as best you can.

To fully complete the registration process please email to us one proof of photo identification (i.e. passport/UK driving license/national idenfication card/travel document) and one proof of address (i.e. utility bill/telephone bill/credit card bill/tenancy agreement/council tax bill) dated within the last 4 months. Please email the images of your documents (i.e. scanned copies/pictures) in a standard format (i.e. pdf/jpeg) to register.whmc@nhs.net.

If you cannot email to us the above documents please do come in person and we will photocopy your documents and attach them to your file.

PLEASE ALLOW 2 WORKING DAYS TO PROCESS YOUR ONLINE REGISTRATION THEN BOOK AN APPOINTMENT IF YOU REQUIRE MEDICATION. IF YOU REQUIRE MEDICATION SOONER PLEASE SPEAK TO RECEPTION.

N.B Please be aware that if you are on highly addictive or controlled medications (i.e. tramadol, diazepam, temazepam etc) that we are unable to prescribe these medications until we have your old medical records, so please liaise with the reception to ensure we have these before booking an appointment. Please also note that we do not prescibe out of accordance with national and local medicines management guidelines.   

For Details about the Summary Care Record, CIDR and Care.data please go to the following links:https://digital.nhs.uk/summary-care-recordshttps://cidrportal.nhs.uk/

*Please ensure you complete all the mandatory sections in order to be able to submit and process the application form. All the mandatory sections are starred * 

1Patient's Details*

i.e maiden name

2Please help us trace your previous medical records by providing the following information

This includes the name of the GP surgery/medical centre/health centre/medical practice

3If you are from abroad (please go to the section if this does not apply to you)

Please ensure that you complete this section if you have come from abroad - otherwise we may not be able to process your application, especially if you have not been previously registered with an NHS GP

4If you are returning from the Armed Forces (please go to the section if this does not apply to you)

5Background information

6About your health

7Family Health History

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.

8Females Only

9NHS Organ Donor registration

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 ON THE ORGAN DONOR REGISTER. For more information, please visit the website www.uktransplant.org.uk or call 03001232323

10NHS Blood Donor registration

11FORM COMPLETION SIGNATURE

12Supplementary questions for all patients whom are not ordinarily resident in the UK (please go to the section if this does not apply to you)

Anybody in England can register with a GP practice & receive free medical care from the 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 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 teats 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.

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, rega

13Complete 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 (please go to the section if this does not apply to you)

If yes, please enter details from your EHIC or PRC below

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 purposes of recovering your NHS costs from your home country.

14Summary Care Record

15CIDR (Clinical Integrated Digital Record)

16Thank you for taking the time to complete this form

17Patient online access

Although sending information across the Internet means that privacy of data cannot be absolutely guaranteed, our online forms offer high levels of security. The forms use HTTPS and TLS (using a 2048 bit certificate) to encrypt data sent to and from your computer when using the site and our server environment is PCI DSS certified - the highest standard of security associated with e-commerce and online finance solutions.

Form submissions are stored on the server for 28 days and are encrypted and secured with a private key known only by the GP Practice.

Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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