New Patient Registration

This form is for over 18 years only

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.

Out of Area Patients

Should a patient move outside of our practice area they will be given 30 days to re-register at another practice within their area, and during this time they will not be entitled to a home visit by Wonersh Surgery.

After the 30 day period has lapsed they will automatically be deducted from our patient list.

Temporary registration

If you are ill while away from home or if you are not registered with a doctor but need to see one, you can receive emergency treatment from the local GP practice for 14 days. After 14 days you will need to register as a temporary or permanent patient.

If you are ill while away from home or if you are not registered with a doctor but need to see one you can receive emergency treatment from the local GP practice for 14 days. After 14 days you will need to register as a temporary or permanent patient.

New Patient Registration - Wonersh

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Patient's Details

Please specify:

Surname: *

Previous Surname(s):

First Name(s) *

Sex *

Male

Female

Indeterminate

NHS Number:

Town and Country of birth: *

Home Address: *

Postcode: *

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

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

Your previous address in UK:

Please include postcode.

Name and address of previous GP practice:

If you are from abroad

Your first UK address where registered with a GP:

Date you came to live in the UK:

Please use this date format: DD/MM/YYYY.

If you are previously a resident in the UK

Date you left the UK:

Please use this date format: DD/MM/YYYY.

Date you returned to the UK:

Please use this date format: DD/MM/YYYY.

Were you ever registered with an Armed Forces GP

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.

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:

Regular

Reservist

Veteran

Family Member (Spouse, Civil Partner, Service Child)

Full address before enlisting:

Please include postcode.

Service/Personnel Number:

Enlistment Date:

Please use this date format: DD/MM/YYYY.

Discharge Date (if applicable):

Please use this date format: DD/MM/YYYY.

If you need your doctor to dispense medicines and appliances

Not all doctors are authorised to dispense medicines

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

I would have serious difficulty in getting them from a chemist

Please select appropriately: *

Signature of patient

Signature on behalf of patient

Signature: *

Date:

NHS Organ Donor registration

For more information on organ donation please visit: www.organdonation.nhs.uk

NHS Blood Donor registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323

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 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

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:

Print Name:

On behalf of:

Relationship to patient:

Date:

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?

Yes

Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?

Yes

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.

Country Code:

3. Name:

4. Given Names:

5. Date of Birth:

6. Personal Identification Number:

7. Identification number of the institution:

8. Identification number of the card:

9. Expiry Date:

PRC validity period - from:

PRC validity period - to:

S1 Form

Do you have an S1 Form?

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).

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.

Tell us whether you accept cookies

This form is for over 18 years only

Out of Area Patients

Temporary registration

Patient's Details

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

If you are from abroad

If you are previously a resident in the UK

Were you ever registered with an Armed Forces GP

If you need your doctor to dispense medicines and appliances

NHS Organ Donor registration

NHS Blood Donor registration

Supplementary Questions

Ordinarily Resident

European Economic Area (EEA) Country

EHIC/PRC

S1 Form

How will your EHIC/PRC/S1 data be used?

Patient Survey