2023 New Patient Registration Form Barony MC

Fields marked "required" are mandatory. You should only complete this form if you are sure you are eligible to join the practice. Completing this form does NOT automatically register you with the surgery. Your details will be held for a limited period of time during which you are required to present in person to sign and provide proof of your address and identity. Completing this form does not guarantee that you will be accepted onto the practice register. You must also complete the Patient Questionare form

Last Updated: 06/07/2023

Patient's Details

Title *

Mother's maiden name?

First name(s) *

Surname *

Previous Surname *

Sex

Male

Female

Date of Birth *

Place of Birth *

Birth Country *

NHS number ( If known ) *

CHI number ( If known)

Address *

Postcode *

Telephone *

I am a student at:

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

Your previous address in UK *

Name of previous GP while at previous address *

Address of that Doctor/ Surgery *

If you are from abroad

Date you first came to live in UK

Your most recent country of residence? *

If previously resident in UK, date of leaving

If you are returning from the armed forces

Address before enlisting

Service/Personnel No.

Enlistment date

Complete Registration

Signature *

Signature of patient

Signature on behalf of patient

Signed

Date

PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

Anybody in Scotland 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.

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

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. *

Are you a parent or guardian, filling out this form on behalf of a child under 16?

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2023 New Patient Registration Form Barony MC

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