Patient Participation Group form

Provide the details below to register with the Practice. A member of staff may need to telephone you to confirm certain aspects of your Registration.

Patient’s details

Title

Name

First Last

Gender

Date of Birth

DD slash MM slash YYYY

Enter Email Confirm Email

Contact Number

Town and Country of birth

NHS Number (if known), If you know your NHS Number, please provide it Optional

Address

Street Address Address Line 2 City County / State / Region Post Code

Please help us trace your previous medical records by providing the following information

Address of previous GP practice

Street Address Address Line 2 City County / State / Region Post Code

Name of previous GP practice while at that address

Address of previous GP practice

Street Address Address Line 2 City County / State / Region ZIP / Postal Code

If you are from abroad

Your first UK address where registered with a GP

Street Address Address Line 2 City County / State / Region Post Code

If previously resident of UK, date of leaving

DD slash MM slash YYYY

Date you first came to live in UK

DD slash MM slash YYYY

Were you ever registered with an Armed Forces GP

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas:

Address Before Enlisting

Street Address Address Line 2 City County / State / Region ZIP / Postal Code

Service or Personnel Number Optional

Enlistment Date Optional

DD slash MM slash YYYY

Discharge Date (if applicable) Optional

DD slash MM slash YYYY

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

If you need your doctor to dispense medicines and appliances

I live more than 1.6km in a straight line from the nearest chemist. Optional

I would have serious difficulty in getting them from a chemist. Optional

Not all doctors are authorised to dispense medicines

NHS Organ Donation 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. Optional

Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit organdonation.nhs.uk or call 0300 123 23 23 to register your decision.

NHS Blood Donor Registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to give blood. Optional

I have given blood in the last 3 years Optional

My preferred address for donation is different from above, e.g. my place of work Optional

All blood types are needed, especially O negative and B negative. Visit blood.co.uk or call 0300 123 23 23.

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.

I am not ordinarily resident in the UK Optional

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

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.

I have a non-UK EHIC or PRC Optional

I have an S1 Form (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.) Optional

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.

Confirm

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted. All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy. This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Consent

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.