Adult 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: 28/04/2021

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

Only complete this section if you have once been registered with a GP Practice in the UK




If you are from abroad

Complete this section if you have never been registered with a GP Practice before in the UK or have recently moved to the UK




If you are returning from the armed forces

Only complete this section if you have returned from the Armed Forces




Complete Registration




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. For more information, please ask for the leaflet on joining the NHS Organ Donor Register




NHS Blood Donor Registration

For more information, please ask for the leaflet on joining the NHS Blood Donor Register






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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Summary Care Record

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. For more information, please visit https://www.digital.nhs.uk/summary-carerecords/patients, call NHS Digital on 0300 303 5678 or speak to your GP Practice.




Patient Participation Group

Coachmans Medical Practice have an active virtual Patient Reference Group. We contact group members from time-to-time via email to ask their opinion about our current services. We will keep our surveys succinct so it shouldn't take too much of your time. This is an easy way of having your say about how your practice is run, without having to commit the time to attending meetings. New members are always welcome. If you are happy for us to contact you occasionally by email please complete this section below. If you have any questions, please speak to the Practice Manager The Partners of the Practice look forward to working with you


Application for online access to my medical record