Leacroft Medical Practice

Have you checked that your are within our practice boundary? *

Yes

No

Please view our practice boundary.

Personal Information

Gender: *

Male

Female

Other (please state):Other (please state):

Surname: *

First Name(s): *

Please Note: The name on this form must exactly match the name on your ID or your application is very likely to be rejected by NHS England.

NHS Number:

I do not wish to state my ethnicity.

Name of Next of Kin: *

Relationship to Next of Kin: *

Address: *

Post Code: *

Telephone Number: *

Please tell us your preferred method of contact: *

Text message

Email

Telephone

Post

Do we have permission to send you text messages? *

Yes

No

Previous Details

Previous address in the UK:

Please include postcode.

Name and address of previous GP:

Country of Birth:

Town of Birth:

If you are from abroad

Registering with the NHS for the first time in the UK

Date you came to live in the UK:

Please use this date format: DD/MM/YYYY

If you are returning from abroad

Previously been registered with the NHS 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

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.

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:

Name:

Given Names:

Date of Birth:

Please use date format: DD/MM/YYYY

Personal Identification Number:

Identification number of the institution:

Identification number of the card:

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.

NHS Organ Donor Registration

If you wish your medical records to be marked that you are willing to donate organs/tissue for transplantation after your death; please tick:

Signature:

Date:

If you would like to join the NHS Organ Donation Register please visit their website on: www.organdonation.nhs.uk/consent.do

NHS Blood Donor Registration

I would like to join the NHS Blood Donor register as someone who may be contacted and would be prepared to donate blood.

Tick here if you haven't given blood in the last 3 years

Signature:

Date:

Leacroft is now a Signposting Practice

Leacroft Medical Practice

CQC Inspected and Rated
Good

We are currently CLOSED.

Leacroft Medical Practice

New Patient Registration

New Patient Questionniare

Personal Information

Previous Details

If you are from abroad

If you are returning from abroad

Supplementary Questions

Ordinarily Resident

European Economic Area (EEA) Country

EHIC/PRC

S1 Form

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

NHS Organ Donor Registration

NHS Blood Donor Registration

Leacroft is now a Signposting Practice

Leacroft Medical Practice

CQC Inspected and RatedGood

We are currently CLOSED.

Digital Practice Help

Make online requests to your GP Practice such as:

Submit self-monitoring health reviews (if requested by the doctor or nurse):

Find the forms that you need:

Give feedback to the Practice:

Get advice on common conditions:

Frequently Asked Questions

How do I make a request to my Practice?

How do I receive the responses from the Practice?

Security of your information

Tracking users

How is the Digital Practice updated?

Suggestions for improvement of the Digital Practice

Links to external sites

Leacroft Medical Practice

New Patient Questionniare

Personal Information

Previous Details

If you are from abroad

If you are returning from abroad

Supplementary Questions

Ordinarily Resident

European Economic Area (EEA) Country

EHIC/PRC

S1 Form

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

NHS Organ Donor Registration

NHS Blood Donor Registration

CQC Inspected and Rated
Good

Submit self-monitoring health reviews
(if requested by the doctor or nurse):