New Patient Application

Complete this form in full to apply to be a registered patient at The Waterloo Practice. Once received we aim to confirm whether or not your application has been successful within 21 days. Please note if you miss your appointment to discuss your application and medication with the GP, your application to join Waterloo Surgery will not be accepted.

Last Updated: 17/10/2023

Patient Details:

TITLE *

Mrs

Miss

Other

SURNAME *

FORENAME/S *

PREVIOUS NAME/S (IF APPLICABLE)

BIRTH TOWN *

BIRTH COUNTRY *

DATE OF BIRTH *

NHS NUMBER (IF KNOWN)

SEX *

Male

Female

Prefer not to say

HOME ADDRESS *

NO. OF PEOPLE AT THIS ADDRESS *

NO. OF DEPENDENTS *

HOME TELEPHONE NO. *

MOBILE TELEPHONE NO.

WORK TELEPHONE NO.

EMAIL ADDRESS

I AM A STUDENT AT

Patient further details:

Out of Area Registrations

Please consider the following information about out of area registrations: - To establish whether you are suitable for out of area registration your application will be passed to a clinician who may contact you to discuss any medical needs and medication that you are taking. We will contact you following this assessment to advise you as to whether we can accept you as an out of area registered patient here. - If you were to develop an urgent illness or injury at home where you require a GP you would always contact this practice in the first instance. If we determined you needed access to services local to where you live we would ask you to call NHS 111. NHS 111 would direct you to the local service that has been established by NHS England for patients such as you. This local service could be a GP practice near to where you live, the local walk-in or urgent care centre, A&E or minor injuries unit. This local service would then decide if you could attend for an urgent face to face appointment with a healthcare professional or if a home visit is indicated which could be based on your individual circumstances. If this were in the out of hours period when GP surgeries are normally closed – between 6.30pm and 8.00am weekdays and during weekends and Bank Holidays – NHS 111 would direct you to your local out of hours provider. - If you are registered as an out of area patient but in time it is felt that your health needs are not being met under this arrangement such that it is no longer clinically appropriate or practical for you to be registered with us, we would expect to discuss this with you and advise that you register with a practice closer to your home.

Are you applying to register as an Out of Area patient? (where your post code does not fall within our practice area - see map on the new patient page of our website) *

Yes No

If you are applying to register as an Out of Area patient, do you agree to the above listed conditions of your registration?

Yes No

PLEASE HELP US TRACE YOUR PREVIOUS MEDICAL RECORDS BY PROVIDING THE FOLLOWING

YOUR PREVIOUS ADDRESS IN THE UK *

NAME OF PREVIOUS GP WHILE AT PREVIOUS ADDRESS *

ADDRESS OF THAT DOCTOR *

IF YOU ARE FROM ABROAD

Have you moved into the UK from abroad? *

Yes No

DATE YOU FIRST CAME TO LIVE IN THE UK

IF PREVIOUSLY RESIDENT IN THE UK, DATE OF LEAVING

YOUR FIRST UK ADDRESS WHERE REGISTERED WITH A GP

IF YOU ARE RETURNING FROM THE ARMED FORCES

ADDRESS BEFORE ENLISTING

SERVICE/PERSONNEL NO.

ENLISTMENT DATE

FURTHER INFO

If you are registering a child under 5

I wish the child above to be registered with the named doctor for Child Health Surveillance

If you need your doctor to dispense medicines and appliances

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

I would have serious difficulty in getting them from a chemist

Signature *

Signature of patient

Signature on behalf of patient

Signed *

Date *

MEDICAL HISTORY

LIFESTYLE

WOMEN ONLY

DO YOU USE CONTRACEPTION?

Yes No

IF YES, PLEASE STATE THE TYPE

ARE YOU CURRENTLY PREGNANT?

YES

POSSIBLY

IF YES, PLEASE PROVIDE YOUR DUE DATE

STUDENTS ONLY

IF YOU ARE LESS THAN 24 YEARS OLD, HAVE YOU HAD 2 DOSES OF THE MMR VACCINATION?

Yes No

IF YOU ARE LESS THAN 25 YEARS OLD, HAVE YOU HAD MENINGITIS C VACCINATION?

Yes No

FURTHER DETAILS

NEXT OF KIN / EMERGENCY CONTACT NAME *

NEXT OF KIN TELEPHONE NO. *

NEXT OF KIN RELATIONSHIP TO PATIENT *

NEXT OF KIN ADDRESS *

ALL OF THE PRESCRIPTIONS WE ISSUE ARE SENT ELECTRONICALLY TO A PHARMACY. PLEASE SUPPLY THE NAME AND LOCATION OF THE PHARMACY YOU WOULD LIKE TO NOMINATE TO RECEIVE YOUR PRESCRIPTIONS *

WOULD YOU LIKE TO BE INVOLVED IN OUR PATIENT PARTICIPATION GROUP (SEE WEBSITE FOR FURTHER INFO) *

Yes No

IF THIS APPLICATION IS FOR A RESIDENT AT A CARE HOME, IS THERE A DOLS IN PLACE

Yes No

IF THIS APPLICATION IS FOR A RESIDENT AT A CARE HOME, ARE THEY ABLE TO ATTEND THE SURGERY FOR APPOINTMENTS?

Yes No

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.

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

Name parent or guardian

Relationship to patient:

Signed

Date

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).

Do you have a non-UK EHIC or PRC?

Yes No

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

Country Code:

Name

Given Names:

Date of Birth

Personal Identification Number:

Identification number of the institution:

Identification number of the card:

Expiry Date:

PRC validity period

a) From:

b) To:

Please tick if 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.

I have an S1 form

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.

Text Messaging

WE EXPECT TO CONTACT YOU VIA SMS TEXT MESSAGING IF YOU HAVE PROVIDED US WITH A MOBILE PHONE NUMBER. IF YOU ARE NOT IN AGREEMENT WITH THIS, PLEASE DOCUMENT BELOW YOUR REASONS FOR THIS:

Reason for opting out of text messaging:

CARER INFORMATION

COMMUNICATION NEEDS

SHARING OUT

This controls whether your full GP electronic patient record can be shared with other NHS Care Services where you are treated.

Please record your preference: *

Sharing Out Yes (shared)

Sharing Out No (not shared)

SHARING IN

This controls whether you agree for this practice to view information you’ve agreed to share at other NHS Care Services.

Please record your preference: *

Sharing In Yes (viewable)

Sharing In No (not viewable)

FURTHER CONSENT

There may be occasions where in an emergency other healthcare providers may need to view parts of your medical record, for example the A&E department, ambulance service etc.

DO YOU CONSENT TO HAVING A SUMMARY CARE RECORD? (ELECTRONIC RECORD WHICH CONTAINS INFO ABOUT MEDICATION, ALLERGIES, SENSITIVITIES AND PAST MEDICAL HISTORY TO MAKE IT EASIER FOR ALL HEALTHCARE STAFF TO TREAT YOU IN AN EMERGENCY) *

Yes No

DO YOU CONSENT TO HAVING AN ENHANCED SUMMARY CARE RECORD? (AS ABOVE WITH ADDITIONAL INFORMATION) *

Yes No

DO YOU HAVE A LIVING WILL / ADVANCE CARE DIRECTIVE / POWER OF ATTORNEY / DNACPR? *

Yes No

IF YES, PLEASE PROVIDE DETAILS BELOW AND PROVIDE A COPY OF ANY RELEVANT DOCUMENTS:

ONLINE ACCESS

DO YOU HAVE ACCESS TO THE INTERNET? *

Yes No

IF YOU HAVE ANSWERED YES ABOVE: WE WOULD LIKE ALL OUR PATIENTS TO HAVE ACCESS TO THEIR MEDICAL RECORD ONLINE TO ENABLE THEM TO ORDER MEDICATION AND COMPLETE QUESTIONNAIRES. ARE YOU HAPPY FOR US TO CONTACT YOU TO ARRANGE YOUR ONLINE ACCESS?

Yes No

Data Protection

Please see our Privacy Notice on our website to see further information on how we use your patient data. https://www.thewaterloopractice.co.uk/data-protection

SystmOne Shared Patient Record Consent

The medical records for our patients are held on our SystmOne clinical computer system. A number of local community health services, the out of hours doctor service and the local Accident and Emergency service also use SystmOne clinical software. If you are receiving services from these healthcare providers who use SystmOne in addition to ourselves we believe that the patient benefits if we are able to share your information with those providers. Please see the eDSM Patients Guide which you can download on the previous page which explains the share options and how you as a patient controls which providers can gain access to your medical records. We would encourage you to consent for us to share your record into the “pool” and allow us permission to access your record held in that pool.

DECLARATION

I confirm that I have been advised of the systems regarding the sharing of my computerised GP medical record and the opportunity for my GP to access medical information from other health providers who use the same “SystmOne” clinical system. I understand that my GP and other health providers require my consent to share their records of my health care.

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. *

Yes No

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