GMS1 – Family Doctor Service Registration | Pontesbury & Worthen Medical Practice

Patient's details

Title *

Date *

Names *

First

Last

Previous surname/s *

Town and country of birth *

Date of birth *

NHS number (if known)

Current home address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Telephone number *

Previous medical records

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

Previous address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Name of previous GP practice while at the previous address

Address of previous GP practice

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

If you are from abroad

Your first UK address where registered with a GP

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

If previously resident in the UK, date of leaving

Date you first came to live in the UK

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. 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.

Regular
Reservist
Veteran
Family Member (Spouse, Civil Partner, Service Child)

Address before enlisting

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Service or Personnel number

Enlistment date

Discharge date (if applicable)

If you need your doctor to dispense medicines and appliances*

*Not all doctors are authorised to dispense medicines

I live more than 1.6km in a straight line from the nearest chemist
I would have serious difficulty in getting them from a chemist

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

Consent

Enter your name to confirm consent to join the NHS Organ Donor Register.

Date

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

Tick if you have given blood in the last 3 years

Consent

Enter your name to confirm consent to join the NHS Blood Donor Register.

Date

Preferred address for donation (only if different from your home address, e.g. your place of work)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Patient Declaration (optional)

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 boxes

I understand that I may need to pay for NHS treatment outside of the GP practice
I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge (“the Surcharge”), when accompanied by a valid visa. I can provide documents to support this when requested
I do not know my chargeable status

Patient Declaration consent

Enter your name to declare that the information given in this declaration 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.

On behalf of

Relationship to patient

Date

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. 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.

Do you have a non-UK EHIC or PRC?

Yes
No

If yes, please enter details from your EHIC or PRC below:

Name

Given names

Date of birth

Personal Identification Number

Identification number of the institution

Identification number of the card

Expiry date

PRC validity period (from)

PRC validity period (to)

S1 Form

Yes

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 live in the UK but work in another EEA member state). Please give your S1 form to the practice staff.

GMS1 form consent *

Enter your name to confirm that details entered previously are correct.

Gender *

Male
Female