New Patient Registration Form ( GMS1) and Health Questionnaire

Fields marked "REQUIRED" are compulsory. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Your details will be held at the surgery for a limited period of time. You are required to present in person to sign your registration form and provide proof of your address. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 14/02/2022

Patient Registration ( GMS1) section:

Yor details

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

If you are from abroad

If you are returning from the armed forces

Complete Registration

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. For more information, please ask for the leaflet on joining the NHS Organ Donor Register

NHS Blood Donor Registration

For more information, please ask for the leaflet on joining the NHS Blood Donor Register

SUPPLEMENTARY QUESTIONS | 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.


Complete this section if you live in an 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 the GP practice, including at hospital).

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.

Online access

Patient Participation Group

The Practice is committed to improving the services we provide to our patients. To do this, it is vital that we hear from people about their experiences, views, and ideas for making services better. By expressing your interest, you will be helping us to plan ways of involving patients that suit you. It will also mean we can keep you informed of opportunities to give your views and up to date with developments within the Practice. If you are interested in getting involved, please let us know.

Summary Care Record ( SCR)

Patients in England have a Summary Care Record. The basic Summary Care Record is an electronic record of important patient information such as medication you’re on and what you’re allergic to. This is held centrally by the NHS and can only be accessed by authorised healthcare staff. There is now an option to add “Additional Information” to your Summary Care Record. This makes the Summary Care Record a much more useful source of information for departments like A&E and the Ambulance service if they need to treat you in an emergency. The information that will be included in your Summary Care Record if you choose to add it is:  Significant medical history (past and present)  Reasons for medication  Anticipatory care information (such as information about the management of long term conditions)  Communication preferences  End of life care information  Immunisations A full list of the terms that will be included in this additional information is available here: Specific sensitive information like fertility treatments, sexually transmitted infections, pregnancy terminations and gender reassignment will not be automatically included when the information is added. If there are any particular items that you would like to be either included or excluded from your Summary Care Record, your GP surgery can mark these items for you in your health record.

Sharing Your Medical Record

This Data sharing allows NHS organisations who are caring for you (e.g. hospitals, specialist consultants, or the community Nurses) to see your health record and / or record data which in turn your GP will able to see on our end. (Provided, their computer system supports this). Petworth Surgery allows data sharing as a default option with local NHS Care providers. It’s important to note that this is not something people can just look at, they need to be actively caring for you. Should any other NHS care provider require access to your shared record, they must seek permission to view the record. For example: If you need a visit from one of the community nurses, they will be able to see your health record and they are also able to add information to your record, so your GP can have a better overview of your care. However if, let’s say, you are on holiday in Cornwall and you injure yourself and end up at the A&E of the local hospital they will have ask your permission (permission to view) to access your record for the period of time they actively provide care for you. The only exception to the “permission to view” is if you are unable to give consent for some reason, such as being unconscious, and a member of staff deems it medically necessary to access your record. In this case, they can perform an override to access you notes, but they must state the reason why they are doing it. When this happens, an alert is also generated for the appropriate Caldicott Guardians to check that the access was appropriate. Also it may be necessary to share data held in GP practices with, let's say, the district nurses but the local podiatry department would not need to see it to undertake their work. In this case, we will allow the podiatry department to share data they record, for you, with us, but they will not be able to see any part of your record held by the surgery. patients would allow the surgery to share their data. If there are particular parts of your record that you would like to remain private, but you are happy to share the rest, then just inform your GP surgery of which items you would like to be private and they can mark them as so. If you don’t want this sharing option to be enabled please let your surgery know so they can opt you out. You can always change your mind.

Next of Kin


Do Not Attempt Cardiopulmonary Resuscitation Decision

Proof of Identity and Address Provided

Health Questionnaire

Information About You

Specific needs:

Please detail below any specific needs you have so the Practice cab ensure they are identified and accommodated by taking the appropriate action

Medical Information







Family History

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)


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