Adults registration form – Fairhill Medical Practice

Online Registration Form – Adult 16+

PATIENT DETAILS
Full Name*
Prefix First Middle Last
Gender from Birth*
- Male
- Female
Date of Birth
Day
Month
Year
Which branch would you like to be registered with? (Kingston University Students will be automatically registered at the Health Centre)*
- Kingston Hill Branch
- Fairfield Branch
- Health Centre (University Branch)
**Please note that only Kingston University students can be registered at the Health Centre**
Student ID Number (Kingston University students only)
Address*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code
(For University Students, your term time address)
Telephone Number (Mobile)*
NHS No.
Email*
Ethnicity*
Town & Country of Birth*
First Language Spoken*
Year of Completion of Studies (Kingston University Students only)*
Are you a carer for anyone with a medical condition who would not manage without your help?*
- Yes
- No
Are you a carer for anyone with a medical condition who would not manage without your help?*
- Yes
- No
Do you have a carer?*
- Yes
- No
If you answered yes to the previous question, what is your Carers name?*
Please help us to trace your previous medical records by providing the following information
Your LAST UK address (NEW TO UK please input N/A in all boxes)*
Street Address City County / State / Region ZIP / Postal Code
(where you were registered with an NHS doctor)
Name of current Doctor (NEW TO UK please input N/A the box)*
Name of Practice (NEW TO UK please input N/A the box)*
Have you recently arrived from abroad?*
- No
- Yes
If Yes, the date of arrival in the UK:*
MEDICAL / PERSONAL / VACCINATION INFORMATION
Do you smoke?*
- No
- Yes
If yes - How many per day approx?*
Height*
Weight*
Waist Circumference*
Do you have allergies?*
- No
- Yes
(including medication)
If yes, please give details*
Do you suffer from any medical conditions?*
- No
- Yes
If yes, please give details*
Any regular medication?*
(If none, please add N/A to this box)
Family History
Is anyone in your immediate family affected by any of the following?*
- Asthma
- Diabetes
- Glaucoma
- Blindness
- Tuberculosis
- Heart Disease
- Infectious Disease
- High Blood Pressure
- Epilepsy
- Thyroid Disease
- Cancer
- Other
If you selected yes to 'Cancer', what type of cancer?*
(If known)
If you selected yes to 'Other', please give details*
Health Check
Would you like a new patient health check?*
- Yes
- No
(Over 16's only, if you would like this new patient health check then please contact the surgery you are registered at)
As part of our screening programme we offer a HIV and Chlamydia Test. Please tick if you wish to opt in:
(18-24yrs and Kingston University Students only)
- HIV Test
- Chlamydia Test
Alcohol Consumption
How often do you have a drink that contains alcohol?*
- Never (0)
- Monthly or less (1)
- 2-4 times a month (2)
- 2-3 times a week (3)
- 4 or more times a week (4)
How many standard alcoholic drinks do you have on a typical day when you are drinking?*
- 1-2 (0)
- 3-4 (1)
- 5-6 (2)
- 7-8 (3)
- 9+ (4)
How often do you have 6 or more standard drinks on one occasion?*
- Never (0)
- Less than monthly (1)
- Monthly (2)
- Weekly (3)
- Daily or almost daily (4)
Next of Kin
Full Name*
Prefix First Last
Relationship to you*
Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Phone
Consent for Summary Care Record sharing*
- Yes
- No
If you have a summary Care Record, your health care providers can view your: - Medication (last 12 months) - Bad reactions to medicines - Allergies When you're admitted to hospital, when treating you in an emergency or when your practice is closed.
Consent for EMIS sharing*
- Yes
- No
Enables your local Kingston Care Providers, when they are treating you to view the relevant information about the care you receive to give you the best possible care.
Accessing my Summary Care Data Record
*
- I wish to access my medical record online and understand and agree with each statement
- I have read and understood the information leaflet provided by the practice
- I will be responsible for the security of the information that I see or download
- If I choose to share my information with anyone else, this is at my own risk
- I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement
- If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible
- I understand that my medical record is designed to be used by clinical professionals to ensure that I received the best possible care. Some of the information within my medical record may be highly technical, written by specialists and not easily understood. It may be best not to access my notes for the first time in the evening or at weekends when the surgery may be closed.
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 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 ordinarily residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP Practice. 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. Please tick one of the following:
- I understand that I may need to pay for NHS treatment outside of the GP Practice
- I understand I have a valid exemption from paying for NHS treatment outside of the GP Practice. This includes for example, an EHIC or payment of the Immigration Health Charge (“the surcharge”), when accompanied by a valid visa, I can provide documents to support this when requested.
- I do not know my chargeable status
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.

Signed	Print Name	On behalf of	Date	Relationship to patient

Complete 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
Do you have a non-UK EHIC or PRC?
- Yes
- No
If yes, please enter details from your EHIC or PRC below:
Country Code
Name
Given Names
Date of Birth
Personal Identification Number
Identification number of the institution
Identification number of the card
Expiry Date
PRC validity period from -
PRC validity period to -
Please tick if you have an S1 (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 you 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.
Signature*
Please type name if completing form online and tick the button below:
*
- Agreed Electronically
Date*
Date
MM slash DD slash YYYY

Online Registration Form – Adult 16+

PATIENT DETAILS

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

MEDICAL / PERSONAL / VACCINATION INFORMATION

Family History

Health Check

As part of our screening programme we offer a HIV and Chlamydia Test. Please tick if you wish to opt in:

Alcohol Consumption

Next of Kin

Accessing my Summary Care Data Record

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

Complete 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

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

How will your EHIC/PRC/S1 data be used?