New Patient Registration

Rydings HallNew Patient Registration

First please confirm you fall within our catchment area using the map below.

You can register by filling out the below form, alternatively please our patient registration pack here.

Patient Registration
Title*

MrMrsMissMs
Surname*
First names*
Date of birth*

DayMonthYear
Date
Place of birth*
Previous surname
NHS Number
Gender*

MaleFemaleOther
Home Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Telephone Number*
Mobile Number
Do you wish to receive appointment reminders or test results by text*

YesNo
Email
If email address is provided this is deemed as consent to use as a contact method
If you are registering a child under 5: I wish the child above to be registered with the doctor and agree to engage with the Childhood Vaccination Programme vaccination against communicable diseases.

YesNo
Your Previous Address in UK

Street Address

Street Address Line 2

CityCounty

Postcode
Address of previous doctor*

Street Address

Street Address Line 2

CityCounty

Postcode
We may use this information to contact your previous surgery to confirm that the information you have provided is correct.
Have you recently moved to the UK*

YesNo
Date of leaving*

DayMonthYear
Date
Date you first came to live in the UK*

DayMonthYear
Date
Your first UK Address where you registered with a GP*

Street Address

Street Address Line 2

CityCounty

Postcode
Have you served in the armed forces?*

YesNo
Address before enlisting

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Service or personnel number*
Enlistment Date*

DayMonthYear
Date

Ethnicity: The collection of this data is in accordance with the legislation contained in the Race Relations Act and follows the recommendations of the Commission for Racial Equality (CRE). The categories of race origin listed below follow the recommended categories for public bodies in England and Wales, and are consistent with the presentation and collection of ethnicity detail within the 2001 Census. Please indicate your ethnic origin. This is not compulsory, but may help with your healthcare, as some health problems are more common in specific communities, and knowing your origins may help with the early identification of some of these conditions.
Please tell us your ethnicity.
White

BritishIrish
Any other White background please write in below
Mixed

White and Black CaribbeanWhite and Black AfricanWhite and Asian
Any other Mixed background please write in below
Asian or Asian British

IndianPakistaniBangladeshi
Any other Asian or Asian British background please write in below
Black or Black British

CaribbeanAfricanWhite and Asian
Any other Black or Black British background please write in below
Chinese or other ethnic group

Chinese
Any other Chinese background please write in below
Do you speak English?*

YesNo
What is your first language
Do you require an interpreter?*

YesNo
Your responsibilities:
- Comply with recommended treatment
- Participate in appropriate practice, national and local screening and prevention programmes
- Commit to a healthy lifestyle with support from the Practice if required
- Attend booked appointments or contact the practice in plenty of time if unable to do so
- Treat GPs and staff with dignity and respect at all times and adhere to the NHS zero tolerance policy.
Practice responsibilities:
- Offer access to quality medical services
- Provide access to a wide range of practice, national and local screening and prevention programmes
- Offer support from trained healthcare professionals to help you to maintain a healthy lifestyle
- Enable you to pre-book relevant appointments and provide you with an appointment with a GP or appropriate healthcare professional
- Treat you with dignity and respect at all times.
Information about all the services we provide and the policies are detailed on our website www.rydingshallsurgery.org.uk/. If you do not have access to the internet please ask at reception for a practice booklet.

Before deciding that you wish to join the Practice we ask that you review this information in order to decide whether you can follow the policies presented by the Practice in line with the new General Medical Services GP contract.
Access, Carers and Prescriptions
Is the practice accessible to you?

YesNo
Do you have any additional needs the practice should be aware when communicating with you?

YesNo
If yes, details
Are you a carer?

YesNo
If you have answered yes to B or C please ask for a Carers identification form to complete, and a Carers pack.
Are you on repeat medication?

YesNo
Allergies if know
If you are on repeat medication please provide us with your repeat prescription counterfoil from your previous practice, a GP or hospital letter containing details of your current medication to enable us to dispense your medication. We operate a Practice Formulary, which is a list of drugs that we are prepared to prescribe so that we prescribe drugs that we are confident in and familiar with. Certain treatments may not be prescribed by the Practice.
Next of Kin

First NameLast Name
Emergency Contact Details
Do you have a DNAR (Do Not Resuscitate) in place
Date of DNAR

DayMonthYear
Date
DETAILS OF OUR FULL RANGE OF SERVICES CAN BE FOUND ON OUR WEBSITE

www.rydingshallsurgery.org.uk

Patient Health Questionnaire

Please complete the following
Weight in kg/ or St/ Lbs*
Height: cm/m/feet/inches*
Smoking Status*

Ex-SmokerNever SmokedElectronic CigaretteSmoker
We have a Smoking Cessation Service to helpsmokers quit. If you smoke would youconsider help to stop smoking?*

Yes, i am happy for you to contact meI shall make an appointmentNo, I don't want to stop at present
How often do you have a drink containing alcohol?*

NeverMonthly or less2-4 Times per month2-3 Times per week4 Times per week
How many units of alcohol do you drink on a typical day when you are drinking (see diagram above)*

1-23-45-67-910+
How often have you had 6 or more units (females) or 8 or more units (males) on a single occasion in the last year?*

NeverLess than monthlyMonthlyWeeklyDaily or almost every day

Have you had any of the below conditions?

Anxiety / DepressionAsthmaAtrial FibrillationCancerChronic Obstructive Pulmonary DiseaseContraceptive ImplantContraceptive CoilCoronary Heart DiseaseDiabetesEpilepsyHigh Blood PressureInfection risk, such as Hepatits b, HIVOther Psychiatric conditionOver active ThyroidPrevious Attempted SuicideRheumatoid ArthritisStrokeSubstance MisuseUnder Active Thyroid
If you have been diagnosed with either COPD or asthma within the last 6 months, please advise of the date of diagnosis / month (if known)

DayMonthYear
Date
If you have been diagnosed with cancer in the last 3 months, please advise of the date of diagnosis / month (if known)

DayMonthYear
Date
Children under 16 (Please supply us with a copy of the red book, with this form, so we can ensure immunization info is up to date.

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Does the child live with someone other than a parent?

YesNo
Relationship to child
Please give details of person/authority with parental responsibility including contact details*
Is there an allocated social worker?

YesNo
Please give details including contact number/email address
Any other significant information we should be aware of?
All the information I have given above is correct to my knowledge

Clear
Date of signature

DayMonthYear
Date

SUPPLEMENTARY QUESTIONS

PATIENT DECLARATION for all patients who are no 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

I understand that I may need to pay for NHS treatment outside of the GP PracticeI understand I have a valid exemption frompaying for NHS treatment outside of the GP practice. This includes for example, an EHIS, orpayment of the Immigration Health Charge (“ the Surcharge”), when accompaniedby a valid visa. I can provide documentsto support this when requested.I do not know my chargeable status 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.
Signature

Clear
Date of Signature

MonthDayYear
Date
On behalf of
Relationship to patient
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.

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETALS AND S1 FORMS
Do you have non-UK EHIC or PRC?

YesNo
County Code
Name

First NameLast Name
Given Names
Date of birth

DayMonthYear
Date
Personal Identification Number of the card
Identification number of the institution
Identification number of the card
Expiry Date

DayMonthYear
Date
PRC Validity Period From

DayMonthYear
Date
PRC Validity Period To

DayMonthYear
Date
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 line in the UK but work in another EEA member state). Please give your S1 form to practice staffI do not have an S1
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 and recovery. Your clinical data will not be shared in the cost recovery process.

Your EHIC, PRC or S1 information will be shared The Department of Work and Pensions for the purpose of recovering costs from your home country

Application for Online Access to Medical Records
Name

First NameLast Name
Date of birth

DayMonthYear
Date
Address

Street Address

Street Address Line 2

CityCounty

Postcode
Email Address
Telephone number
Mobile Number
I wish to have access to the following online services (please tick all that apply):

Booking appointmentsRequesting repeat prescriptions
I wish to access my medical record online and understand and agree with each statement

I have read and understood the information leaflet provided by the practiceI will be responsible for the security of the information that I see or downloadIf I choose to share my information with anyone else, this is at my own riskI will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreementIf I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible
Signature

Clear
Date of signature

DayMonthYear
Date
Please provide us with one piece of photographic ID and one proof of address. Please allow 40 days for processing.

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Should be Empty:

New Patient Registration

Patient Registration

Access, Carers and Prescriptions

Patient Health Questionnaire

Application for Online Access to Medical Records