RPC New Patient Registration Form

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. Your details will be held at the surgery for a limited period of time. You are required to present in person to sign your registration form and provide proof of your address. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 25/10/2021

Patient's Details














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




If you are from abroad




Non-UK EHIC or PRC

Please complete this section if you live in another EAA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EAA member state. Do not complete this section if you have an EHIC issued by work. By using your EHIC 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 with the cost recovery process. Your EHIC PRC or S1 information will be shared with the The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.















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 resiliently 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 test of suspected infectious diseases and any treatment of those disease 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, 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 the 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.

If you are returning from the armed forces




Contact Preferences







Relations






Are you a carer?

If no, please skip to the following section







Do you have a carer?

If no, please skip to the following section




If you are registering a child under 18 years old, please read and complete the section below




Parental Responsibility - Please give details below of who has Parental Responsibility for the child being registered:

Consent for treatment can only be given by the person/s with parental responsibility** for the child receiving the treatment ** Biological mothers always have parental responsibility for their child (unless rights have been removed by a court order). All other parents/guardians can acquire parental responsibility in various ways: - Where the parents are married at the time of the birth the father will automatically have parental responsibility - In the case of the child being born after 1 December 2003, where the fathers details are registered on the birth certificate the father will also have parental responsibility even if parents are unmarried. - If the parents are unmarried at the time of birth and the father is not named on the birth certificate a father does not have parental responsibility unless a formal agreement with the mother has been acquired, by order of the Court or by obtaining a residence order (which governs where a child is to live) in relation to the child. With a parent's consent others (e.g. partner, other relatives etc) can obtain parental responsibility in relation to the child either by entering into a parental responsibility agreement, or on application to the court. Parental responsibility gained in this way will not be lost unless rights have been removed by a court order. Parental responsibility is also obtained through the making of a residence order (an order made under the Children Act 1989), and through the act of adoption.










New Patient Questionnaire




Your General Health













Record Sharing Opt-out Form



Confirmation