New Patient Registration Form

KPMC Adult Reg
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Patient’s Details

Please Note: We need district of birth e.g. Kensington, London
This must be a UK number
This must be a UK Number
Are you happy for us to contact you by text message?
We rely on text messages to quickly send patients appointment reminders and provide essential health information. Are you sure you do not wish to be contacted by text message
Are you happy for us to contact you by letter?
Are you happy for us to contact you by email?
Please provide an email address as we aim to increasingly use this to communicate with patients

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

(if you do not have a previous UK address enter N/A)
(if you do not have a previous UK postcode enter N/A)
(if you do not have a previous Doctor enter N/A)
(if you do not have a previous Practice enter N/A)

Are you from abroad?
If you have never registered with a GP in the UK, write NONE

Are you returning from living abroad?

Are you returning from living abroad?

Language

Do you speak English?
Can you read English?
Do you need an interpreter when you see the doctor?
Are you an Asylum seeker?
Are you a refugee?
Are you homeless?

Members of the Armed Forces & Veterans

Are you returning from the armed forces?

Getting to the practice

Are you housebound and unable to get to the practice?

NHS Organ Donor registration

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

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

NHS Blood Donor registration

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

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: blood.co.uk.

Supplementary Questions

PATIENT DECLARATION for all patients who are not ordinarily resident in the UK.

Are you Ordinarily Resident in the UK?

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

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

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.


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.