New Patient Registration

If you would like to register with the practice please use this form.

To register a new patient you will need to live within our practice boundary, however since January 2015 all GP practices have been free to register new patients who live outside their practice area without any obligation on the practice to provide home visits for such patients when the patient is at home, away from, and unable to attend, their registered practice.

New Patient Registration

The lawful and proper treatment of personal information by the practice is extremely important to the success of our business and in order to maintain the confidence of our services to you, the patient. Please note the surgery uses a ‘Call board’ to direct patients to their appointment.

Patient's Details

Title *
Please use this date format: DD/MM/YYYY.
Gender *
Any responses we send will go to this email address.
What is your preferred contact number? *
Can we contact you by text? *
Can we contact you by email? *
Can we leave you voicemail messages? *

Armed Forces

Have you worked within the Armed Forces? *
Do you have a relative who is, or has been, in the Armed Forces? *
Please indicate your Armed Forces status *
Please state which relative is, or has been, in the Armed Forces *

Ethnicity

Please specify the ethnic group you consider you belong to: *
Do you speak English?
Do you read English?
Do you need an interpreter? *

Emergency Contact

Are they your next of kin?
Do you give us permission to discuss your medical records with them?

Previous Details

Do you have a previous UK address? *
Are you currently registered with another GP? *
Please include postcode.

If you are from abroad

Registering with the NHS for the first time in the UK
Please use this date format: DD/MM/YYYY.

If you are returning from abroad

Previously been registered with the NHS in the UK
Please use this date format: DD/MM/YYYY.
Please use this date format: DD/MM/YYYY.

Supplementary Questions

I am not ordinarily a resident in the UK

Ordinarily Resident

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. Alternatively for more information go to www.nhs.uk/visitingengland.

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 select one of the following statements:

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.

A parent/guardian should complete the form on behalf of a child under 16.

European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea
Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?
Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?

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 of the GP practice, including at a hospital.

EHIC/PRC

Please enter the details from your EHIC or PRC below.

S1 Form

Do you have an S1 Form?
Please give your S1 form to the practice staff.

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.

Carers

A carer is a friend or family member who gives their time to support a person in their home, to an extent that the person could not remain at home if this care was not being provided. A carer can receive Carers Allowance, but not a wage and the care they are giving will significantly affect their own life.

Are you looked after by someone whose support you could not manage without?
Do you consent for your carer to be informed about your medical care?
Do you have a Power of Attorney
Do you look after or support someone who couldn’t manage without you?
Do you look after someone who is a patient of Market Harborough and Bosworth Partnership?
Are they a: