Muswell Hill Practice New Patient Registration Form (GMS1) + Health Questionnaire

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. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register. Before You Register This is a long form, it may be useful to have to hand: Your NHS Number (if you have one), the address of your previous doctors surgery (if you have one), the date you arrived in the UK (if you weren’t born in the UK), your EHIC Card or PRC (If you do not ordinarily live in the UK and have one of these), your Armed Forces personnel number and start date (If you served in the Armed Forces), a photo or scanned copy of a proof of address (eg utility bill dated in the last 3 months) to email in. Please note: You can only be registered with one GP practice. If you register with us, you will be de-registered from your current GP practice. Please allow 5 working days for your registration form to be processed.

Last Updated: 14/09/2020

Initial Questions



Next of Kin

Please give us the details of who to contact in case of emergency, this can be a friend or family member.




Your Details

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















Ethnicity and languages





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




Contact with the Surgery

Important questions to help you use our services



If you are from abroad




NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

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 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 the GP practice, including at hospital).















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.


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.







If you are returning from the armed forces




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






Height and Weight




Medical History



Alcohol

The questions below refer to a standard drink which means either: half a pint of ordinary beer/lager/cider; a single measure of spirits; a small glass of wine; or a small glass of sherry. Each answer is scored by a number of points, found in the brackets at the end of the answer. Please add up your points as you answer the questions, you will be asked for this number at the end of the section.













Allergies

Please tell us about any allergies or any adverse reactions to medication prescribed in the past:



Carer

A carer is someone who looks after an adult or a child with a chronic disease, mental health problem, learning or physical disability, sensory impairment or who are otherwise unable to care for themselves (i.e. this does not include a parent of a normal child)





Smoking




Communication Support






Electronic Prescriptions (EPS)

Prescriptions can now be sent direct to a pharmacy of your choice. This is called nomination. This can be set up with a pharmacy near to where you live, work or shop. You no longer have to visit the practice to pick up your paper prescriptions, they can be sent electronically to the pharmacy you choose saving you time. All you need to do is fill in the information below and the practice can set this up for you. Alternatively, you can ask your pharmacist to set this up. You can change or cancel your nominated pharmacy at any time. Please ask at reception if you would like any more information on EPS.


Proof of Identity and Address

We need to verify your address and identity, please could you now email a copy of the documents listed below to: harccg.admin.tmhp@nhs.net Please put your name and date of birth in the subject box of the email. Please do not click completed and click ahead until you have sent this. Clicking ahead without sending us these documents will significantly delay your registration.



Patient Agreement

Thank you for registering at The Muswell Hill Practice. We welcome you here and aim to provide a high standard of service to all our patients. In order for us to maximise the service we are able to give, we request that patients agree to the following requests. Patients will be warned should this happen and it may result in a removal from the practice list.




Summary Care Record Opt Out Form

A Summary Care Record is a way of telling health and care staff important information about a person. For people with a learning disability, autism or both a doctor might ask if they can add some additional information to the summary care record. This will mean if a person needs treatment by other services like emergency or urgent care they will have more information about them. If you choose to opt out, NHS healthcare staff caring for you may not be aware of your current medications, allergies you suffer from and any bad reactions to medicines you have had, in order to treat you safely in an emergency. Your records will stay as they are now with information being shared by letter, email, or phone. If you have any questions, or if you want to discuss your choices, please contact the practice. It tells staff caring for someone about their medicines and allergies. This means they can look after the person if they are not at their usual doctor’s surgery.