New Patient Registration - Babies & Children

Important Notice for New Patient Registration

We will only register patients who are within our practice area. Please use the postcode checker with the map on this page to make sure you are within our area BEFORE you complete the online form.
You will not be registered with the practice until you have provided the practice with photo ID and proof of address.

We are happy to receive enquiries about joining our Patient list from anyone who lives in the practice area.

When registering with the practice you will need to complete the online registration form below, or request the forms from reception..

You must attend the practice with photo ID and proof of address please as the registration won't be processed until we receive this.

Practice Area

Use the postcode checker below to see if you are within our practice area. If you are not within our practice area please do not try to register with the practice.

New Patient Registration - Babies & Children

Title

First names

Surnames

Previous surnames

Date of Birth

Gender

Town and country of birth

NHS Number

Address

Home Telephone

Work Telephone

Mobile Telephone

Do you consent to being contacted by SMS on this number

Do you consent to being contacted by email at this address

It is your responsibility to keep us updated with any changes to your telephone number, email & postal address. We may contact you with appointment details, test results or health campaigns

Next Of Kin Details

Next of Kin Name

Next of Kin Telephone

Relationship to you

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

Your previous address in UK

Name of previous GP practice while at that address

Address of previous GP practice

If you are from abroad

Date you first came to live in UK

Were you ever registered with an Armed Forces GP

Has the child been registered with an Armed Forces GP

If you need your doctor to dispense medicines and appliances*

* Not all doctors are authorised to dispense medicines

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

Would you have serious difficulty in getting them from a chemist

PATIENT DECLARATION 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.

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.

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.

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.

Do you have a non-UK EHIC or PRC

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

Country Code

Name

Given Names

Date of Birth

Personal Identification Number

Identification number of the institution

Expiry Date

PRC validity period from

PRC validity period to

Do 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).

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.

Named Accountable GP

Every patient at our practice has a named accountable GP who is responsible for their overall care at the practice. Unless you are told otherwise, this is the GP you are registered with, but this does not stop you from seeing any other GPs at the surgery.

Permission to View Your NHS Summary Care Record

Your Summary Care Record contains information from your health record such as your current prescription, allergies and any bad reactions to medication you have had in the past. It will also include your name, address, date of birth and your unique NHS Number to help identify you correctly.

Clinicians involved in providing care to you would like to view your Summary Care Record in order to provide the best possible care for you from the most up to date information available.

Only the clinician involved in your care will be able to access your Summary Care Record.

Whenever your record is accessed their details will be recorded should you wish to question this at any point in the future.

You can change this permission at any point just by informing reception

I give permission for a clinician to access my Summary Care Record

Mjog Text Messaging Services

The GP Practice will on occasion wish to send either a SMS Text Message to your mobile phone OR SMS Voice Message to notify you of any or all of the following: Confirmation of your booked appointment, Changes to your booked appointment, National Issues such as Flu Pandemics, Practice being closed due to unforeseen circumstances & Other notifications the practice deem necessary to your health care provision

Disclaimer:

If you agree to the GP Practice contacting you via your mobile or fixed landline number, the GP Practice agrees to adhere to the following:

1. The mobile phone number or fixed land line number will only be used by the GP Practice and will not be passed to any other parties.

2. If at any time you would like to opt out of any of the above services, please make a personal request to the GP Practice and you will be opted out of the service within 48 hours. You may also like to include your reason for opting out to help us review and improve the service in the future.

3. Your mobile number will solely be used by the GP Practice in relation to the healthcare services offered by the GP Practice. You will not be contacted in relation to any other types of products or services.

I consent to:

You must attend the practice with photo ID and proof of address please as the registration won't be processed until we receive this.

I am aware that the registration won’t be accepted until identification is provided to the practice

Practice Area

I confirm that I have used the postcode checker and I am within the practice area

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.

I consent to my information being used for the purposes described above and wish to submit this online form to Penn Surgery • 2a Coalway Road, Penn, Wolverhampton, WV3 7LR.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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