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Register with a General Medical Practitioner (GMS1)

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General Medical Practitioner (GMS1)

Application to register with a General Medical Practitioner

Please help us by completing the following information. This is very important as it may take some weeks for your medical records to arrive. Click here to download form. 

Patient's Details - Please complete the text boxes and tick where appropriate.

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Telephone numbers:

Please remember to let us know if your contact details change in case, we need to contact you urgently.

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

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If you are from abroad

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If you are returning from the armed forces

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If you are registering a child under 5:

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*Note: all doctors are authorised to dispense medicines

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NHS Organ Donor registration

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply:

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For more information, please ask at reception for an information leaflet or visit the website www.uktransplant.org.uk or call 0300 123 23 23.

NHS Blood Donor registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood:

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For more information, please ask for the leaflet on joining the NHS Blood Donor Register My preferred address for donation is: (only if different from above, e.g. your place of work)

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HA use only

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To be completed by the doctor

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Distance in miles between my patient’s home address and my main surgery is:

I declare to the best of my belief this information is correct and I claim the appropriate payment as set out in the Statement of Fees and Allowances. An audit trail is available at the practice for inspection by the HA’s authorised officers and auditors appointed by the Audit Commission.

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SUPPLEMENTARY QUESTIONS

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 ordinary 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.

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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.

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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

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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.

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

Country Code (e.g. UK, DE etc.):

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PRC validity period

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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.

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How often do you exercise?

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Would you like to give up smoking? Help and treatment is available here. Ask at reception.

Next of kin:

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Have any members of your immediate family (parents, brother, sister) had any of the following:

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If you are on any regular medication, please bring in a repeat prescription slip from your old practice, listing your medication, so that we can put it on the computer. Otherwise, you will have to have an appointment with the doctor before we can give you a prescription. Please allow plenty of time for your prescription to be prepared: we need at least 2 working days for your prescription to be authorised and sent to the pharmacy (and the Pharmacies need another 2 working days for dispensing.)

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If you have a Dossett Box then please ensure you have adequate medication as it can take 6 weeks to organise.

Do you have any allergies to any medicines or substances on your skin?

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Ethnicity:

Please tick the ethnic group which you feel most accurately describes you. These are National codes as defined by the 2001 Census.

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Language:

What is your first language? Please tick. For babies and children please tick the language of their parents

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If you are 16 or over, please complete the following questions

Questions:

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Only answer the following questions if your score is 2 or more

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Scoring: a total of 3 or above indicates hazardous or harmful drinking.

If you scored 3 or more and are interested in finding out a bit more, please ask the receptionist for the longer alcohol audit questionnaire and leaflet.

Practice use only:

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Further information

Zero Tolerance Statement

Our staff come to work to care for others, and it is important for all members of the public and our staff to be treated with respect.
We aim to treat our patients courteously at all times and expect our patients to treat our staff in a similary way.

We take seriously any threatening, abusive or violent behaviour againist any of our staff or patients. if a patient is violent or abusive, they will be asked to stop. if they persist, we may exercise our rights to take action to have them removed, immediately if necessary from our pratice list.

The practice considers thratening behaviour to be:

Attempted or actual aggressive threatening physical actions made towards any member of staff.
The use of aggressive, threatening or abusive language, (including raising of the voice, swearing and cursing, shouting) which threatens or intimidates staff.
In line with the rest of the NHS, and to ensure this is fully observed we have a Zero Tolerance policy in place, whereby any aggressive or violent behaviour towards our staff will not be tolerated under any circumstances.

Anyone giving verbal abuse to members of the staff will be sent a letter from the Practice stating that this behaviour will not be tolerated and may result in the removal from the Practice patient list. There will be no appeal process.

We hope that you will understand and welcome this policy which is in place for the best interest of our hard working staff as well as our patients.

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