Online Pre-Registration « Rothschild House Surgery Group

Patient details

Which practice do you wish to register with?*

Rothschild House Surgery

Markyate Surgery

Berkhamsted

Name*

Please write this in English if applicable

Title First Name Surname Known as

Date of Birth*

Birth Town*

Birth Country*

Sex at Birth*

Male

Female

NHS Number

If you need a doctor to dispense medicines and appliances

Nearest Chemist

I live more than 1 mile in a straight line from the nearest chemist

Chemist Difficulty

I would have serious difficulty in getting them from a chemist

Address*

Street Address Address Line 2 Town County Postcode Country

Home Phone Number

Do you consent to us leaving messages on this number?

Yes

No

Mobile*

Do you consent to receiving text messages to this number?*

Yes

No

Do you consent to us leaving messages on this number?*

Yes

No

Email Address

Do you consent to receive emails to this address?

Yes

No

Marital Status

GMS1 - Please help us trace your previous medical records by providing the following information

Previous Address in the UK*

Street Address Address Line 2 Town County Postcode Country

Have you previously been registered with an NHS GP in UK?*

Yes

No

Name of Previous GP*

Address of Previous GP*

Street Address Address Line 2 Town County Postcode Country

If you are from abroad

Registering with the NHS for the first time in the UK

Date you came to live in the UK

If you are returning from abroad

Previously been registered with the NHS in the UK

Date you left the UK

Date you returned to the UK

Armed Forces

Please indicate if you have ever served in the UK Armed Forces*

Yes

No

Please indicate if you have ever served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas

Regular

Reservist

Family Member

Address before enlisting

Street Address Address Line 2 Town County Postcode Country

Service or Personnel Number

Enlistment Date

Discharge Date

Emergency Contact / Next of Kin

Name

Prefix First Last

Contact Number

Home Address

Relationship to Patient

Are they your next of kin?

Yes

No

Do you give us permission to contact them in an emergency?

Yes

No

Do you give us permission to discuss your medical records with them?

Yes

No

Ethnicity

The Department of Health require us to record the ethnicity and language of every patient registered with the practice. This information will be used to help plan and deliver services appropriate to different communities. The categories below have been used across government since 2001 are taken from the Department of Health's website.

First Language*

If English is not your first language, do you speak English?*

Yes

No

Please specify which ethnic group you belong to:*

Summary Care Record

You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care.

Dear Patient,

If you are registered with a GP practice in England, you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past.

Information about your healthcare may not be routinely shared across different healthcare organisations and systems. You may need to be treated by health and care professionals who do not know your medical history. Essential details about your healthcare can be difficult to remember, particularly when you are unwell or have complex care needs.

Having a Summary Care Record can help by providing healthcare staff treating you with vital information from your health record. This will help the staff involved in your care make better and safer decisions about how best to treat you.

You have a choice

You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care.

Your options are outlined below:

Express consent for medication, allergies and adverse reactions only. You wish to share information about medication, allergies for adverse reactions only.
Express consent for medication, allergies, adverse reactions and additional information. You wish to share information about medication, allergies for adverse reactions and further medical information that includes: your illnesses and health problems, operations and vaccinations you have had in the past, how you would like to be treated (such as where you would prefer to receive care), what support you might need and who should be contacted for more information about you.
Express dissent for Summary Care Record (opt out). Select this option, if you DO NOT want any information shared with other healthcare professionals involved in your care.

If you chose not to complete this consent form, a core Summary Care Record (SCR) will be created for you, which will contain only medications, allergies and adverse reactions.

Once you have completed the consent form, please return it to your GP practice.

You are free to change your decision at any time by informing your GP practice

Summary Care Record patient consent form

Having read the above information regarding your choices, please choose one of the options below and return the completed form to your GP practice :

Would you like your Summary Care Record?*

Yes - Express consent for medication, allergies and adverse reactions only.

Yes - Express consent for medication, allergies, adverse reactions and additional information.

No - I would not like a Summary Care Record (opt out).

Supplementary Questions

These questions and the patient declaration are optional and your answers will not affect your entitlement to register or receive services from your GP.

I am ordinarily a resident in the UK

I am not ordinarily a resident in the UK

Only complete the below if you have ticked 'I am not ordinarily a 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. Alternatively for more information go to www.nhs.uk/visitingengland.

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 boxes:*

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.

European Economic Area (EEA) Country

Complete this section f you live in another EEA country, or have moved to the UK to study or retire, or if you lice in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?*

Yes

No

Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC)?*

Yes

No

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

Country Code

Name

First Last 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

Do 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 your S1 form to the practice staff.

Yes

No

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 mot be shared in the cost recovery process.

Your EHIC, PRC or S1 information will be hared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

Signatures

Signatures*

Patient's signature

Signature on behalf of patient

Electronic Signature (Type your full name here)*

By completing the section above, I hereby sign this form electronically

Signature

Consent*

I agree to the privacy policy.

Comments

This field is for validation purposes and should be left unchanged.

Online Pre-Registration

Registration Form - Adult (16+)

Patient details

If you need a doctor to dispense medicines and appliances

GMS1 - Please help us trace your previous medical records by providing the following information

If you are from abroad

If you are returning from abroad

Armed Forces

Emergency Contact / Next of Kin

Health History

Alcohol Consumption

Smoking

Exercise

Allergies

Medical History

Regular Medication

Family History

Carers

Communication Needs

Patient Participation Group

Ethnicity

Summary Care Record

Supplementary Questions

European Economic Area (EEA) Country

Signatures

Useful Links

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