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: 28/09/2021

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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.


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




IF YOU ARE FROM ABROAD




IF YOU ARE RETURNING FROM THE ARMED FORCES




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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.






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.

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:

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CARER INFORMATION









COMMUNICATION NEEDS








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.

SHARING OUT

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

SHARING IN

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

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.

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.




ONLINE ACCESS





MEDICAL HISTORY







LIFESTYLE












WOMEN ONLY





STUDENTS ONLY



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