New Students Registration Form

Have you read our Patient Privacy Notice? If not, please read HERE before registering.

Yes

No

Your Details

First Name *

Surname *

Previous surnames

Date of Birth *

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

NHS Number

If known.

Gender *

Male

Female

Height *

Weight *

Town of birth *

Country of birth *

Current Coventry Address:

Flat/Room Number: *

Building Name WITH House number and/or Street: *

Town: *

Postcode: *

Home Town Address

House Number and Street: *

Area *

Town *

Postcode *

Contact Details

Do you give us permission to communicate with you by text? *

Yes

No

UK Mobile Number *

Do you give us permission to communicate with you by email? *

Yes

No

Email Address *

Please ensure that your email address is correct.

Have you previously been registered with a GP in the UK? *

Yes

No

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

Your previous address in UK *

Name of previous doctor while at that address *

Address of previous doctor *

If you are from abroad

Date you first came to live in UK *

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

Ethnicity

Please specify

What is your main spoken language? *

Emergency Contact

Full Name *

Telephone Number *

Relationship to you *

Details of University Course and Date

Title of Course *

Course Start Date *

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

Course Completion Date *

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

If you are returning from the armed forces

Address before enlisting

Service or personnel number

Enlistment date

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

Medical History

Please list any important illnesses

Please list any medication you are currently taking

Please note: If you are taking any medication, you will need to see a Doctor before you request a repeat prescription.

Please list any allergies to antibiotics or other medication

Female Students aged 25 and over

Have you had a smear/PAP test in the UK?

Yes

No

Have you had a smear/PAP test in a country other than the UK?

Yes

No

If possible please provide a copy.

Smoking

Do you smoke? *

Yes

No

Would you like help to stop smoking? *

Yes

No

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

No

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

Yes

No

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.

Signature *

Date *

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

Your Details

Current Coventry Address:

Home Town Address

Contact Details

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

If you are from abroad

Ethnicity

Emergency Contact

Details of University Course and Date

If you are returning from the armed forces

Medical History

Female Students aged 25 and over

Smoking

Supplementary Questions

Ordinarily Resident

European Economic Area (EEA) Country

EHIC/PRC

S1 Form

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

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