New Patient Registration Form

Please note that this person will be used as an emergency contact if we cannot reach you in an emergency

All children  registered with the Deerbrook surgery will be eligible for baby checks and immunisations

Previously been registered with the NHS in the UK

Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services

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 at reception. Alternatively for more information go to www.nhs.uk/nhs-services/visiting-or-moving-to-england

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.

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.

For a list of EEA countries visit: www.gov.uk/eu-eea

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.

Please enter the details from your EHIC or PRC below.

Please give your S1 form to the practice staff.

A main carer is defined as the following:

• someone who is in receipt of carers' allowance
• someone who looks after another person that has a significant impairment that would mean they couldn't normally look after themselves
• a parent who has a child with a substantial disability

After registration is complete, please advise the practice if there are any elements of your medical problems that you would not like us to discuss with them

You have the opportunity to see any doctor at the practice. This is to inform you that your named allocated doctor is Dr Imtiaz Ahmad

All new patients are offered an HIV test. Please let our healthcare assistant know if you'd like to take up this offer when you come in for a new patient check

Body Mass Index

Please click here for information and help on how to give up

An AUDIT-C score above 3 for women (and above 4 for men) means you should consider reviewing the way you drink alcohol

Further help including finding local services to help with alcohol consumption can be found here.

As you are registering someone under 16, there is no need for any ID documents to be uploaded. However, if you want to use Online services for this account eg to book appointments, request medications or view the medical record online or via an app, please click yes in the box below and we may require you to upload some documents below or show them to reception:

As you are registering a newborn, there is no need for any ID documents to be uploaded. We will automatically make an online account for the baby, eg to book appointments, request medications or view the medical record online and via an app. If you don't already use Patient Access, please click here to get yourself registered.

Once you're registered on Patient Access, you can link yourself to your child's account by clicking on this guide. Please let us know if you need any help.

In order to be able to use an online account to view your child's record and request medications/book appointments, you need to ensure you are already set up on Patient Access. If you're not set up, please click hereto set this up for yourself. If you are already set up, we can Link you to your child's record by setting you up as a proxy. In order to do this, we will need some ID relating to the child to be uploaded below.Once you've done this below, the child will appear in your account settings after a few days. Click this guide showing how to link them in Patient Access.

Please sign either using your mouse/trackpad or a finger if you are on a touchscreen device

As you're making an online account for a child over 12 years old, we need them to agree to this