www.meddygcare.co.uk
Office Use Only
Please use BLOCK CAPITALS and answer all questions.
Received
Patient Number
The information provided will form part of your medical record.
If you are returning from the Armed Forces, please let us know.
Personal Details
7. If you are from abroad,
the date you came to UK:_______________
1. Mr
Mrs
Miss
Ms
2. Surname: ____________________________
8. Home telephone:____________________
3. First names: __________________________
9. Mobile telephone: ___________________
4. Previous surname(s): ___________________
10. Work telephone: ____________________
5. Marital Status: _________________________
11. Email: ____________________________
6. Occupation: _________________________
12. Date Of Birth: ______________________
Your Ethnic Group 13. Please choose one of the four sections and then tick your ethnic group:
(please tick one box only)
White
Asian or Asian British
White British
Indian
White Irish
Pakistani
Welsh
Bangladeshi
Polish
Other Asian– please write in:
Black or Black British
Chinese or Other
Black Caribbean
Chinese
Black African
Middle Eastern
Somali
Any other – please write in:
Other Black– please write in:
Your Medical History
14. Please indicate if you have been diagnosed with the following illnesses and approximate diagnosis date:
Coronary Heart Disease Date: ....../......./......
COPD
Date:....../......./......
Diabetes
Date:....../......./......
Asthma
Date:....../......./......
Stroke
Date:....../......./......
Stroke
Date:....../......./......
Breast Cancer
Date:....../......./......
Breast Cancer
Date:....../......./......
Bowel Cancer
Date: ....../......./......
Language
15. My main written language is: _______________. My main spoken language is: _____________
16. If English is not your main spoken language, do you need help from a relative or friend when you
visit the doctor? Yes
No
Family History
17. Please indicate any family history of the following illnesses:
Coronary Heart Disease < 60
COPD > 60
Diabetes
Asthma
Stroke < 60
Stroke >60
Breast Cancer < 45
Breast Cancer > 45
Bowel Cancer
If Yes to any of the above, please indicate which relative __________________________________
Lifestyle
18. Do you provide care for someone because of their poor health or disability? Yes
No
19. Are you cared for by someone because of your poor health or disability? Yes
No
20. Are you registered disabled ? Yes
No
21. Do you smoke? I used to smoke
I’ve never smoked
I smoke => cigarettes per day:
If you are a smoker, would you be interested in receiving Smoking Cessation advice?
Yes
No
22. How many units of alcohol do you drink on a weekly basis? (see guide overleaf)
23.
Alcohol Users Disorders Identification
Scoring: A total of 5+ indicates hazardous or harmful drinking
Scoring System
Questions
0
1
2
3
4
How often do you
Monthly or 2 – 4 times 2 – 3 times 4 + times per
have a drink that
Never
less
a month
per week
week
contains alcohol?
How many standard
alcoholic drinks do
you have on a
typical day when
drinking
How often do you
have 6 or more
standard drinks on
one occasion?
1 -2
3–4
5–6
7–9
10 +
Never
Less than
monthly
Monthly
Weekly
Daily or
almost daily
Your
Score
Pint of Regular Beer/Lager/Cider = 2 Units
Alcopop or Can of Lager = 1.5 Units
Glass of Wine (175ml)
= 1.5 Units
Single Measure of Spirits = 1 Units
Bottle of Wine = 9 Units
Health
24. Do you have any Drug (i.e. Penicillin) or Non Drug (i.e. Elastoplast / Latex) allergies? Yes
No
If ‘Yes’, Please give details _______________________________________________________
25. Do you take regular medication? Yes
No
If ‘Yes’, Please give details _______________________________________________________
26. Do you have any long-term illness, or health problem? Yes
No
If ‘Yes’, please give details: _____________________________________________________
27. Do you have any learning or physical disabilities? Yes
No
If ‘Yes’, please give details: _____________________________________________________
28. Height: _______________
27. Weight: _______________ 28. BMI: ________________
29. For patients with a BMI of 30+ we offer healthy lifestyle advice, would you be interested in
this programme? Yes
No
Your Next of Kin / Emergency Contact
30. Next of kin’s name___________________
Relationship to you_____ __
31. Next of kin’s address__________________________
32.Telephone Numbers________________________________
Blood Pressure: 33. If you know your latest blood pressure reading, please let us know here.
BP ............................ /................................
Acceptable Identification Documents for Registration at the Practice
TO BE ATTACHED TO EACH REGISTRATION FORM (OR ONE FOR EACH FAMILY)
Name Identification
Address Identification
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Current signed full passport
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Recent utility bill
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Current UK driving licence
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Local Authority tax bill for current year

Blue disabled drivers pass
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Current benefits or State Pension
notification letter confirming rights to
benefits for the current period.
Credit/Store card statement (but if
produced/ printed from internet
requires letter from account manager
to validate address)

Mortgage Statement

Local Council rent card

Tenancy agreement

Current HMRC tax notification eg
PAYE coding, statement of account
(P45’s & P60’s are not official HMRC
documents)

Shotgun or Firearms Certificate


Solicitors letter confirming recent
purchase of your property
Travel documents issued to foreign
nationals granted permission to remain
in the UK

A letter from your bank manager
confirming your residential address to
be validate and correct to support any
internet produced /printed bank
statements that may be produced.

Current EU/EEA driving licence

Residence permit issued by the Home
Office to EU nationals

EU/EEA member state identity card
Under 16’s
Children under the age of 16 whose Parent/ Guardian is registered with the practice/ registering at
the same time will need to provide either:
 Original Birth Certificate or a certified copy
 Passport
If you are unable to provide any of the above documents please speak to a member of the
reception team who will be able to discuss alternative documents.
Patient Registration Questionnaire, Insurance Details and Patient Declaration
Please provide the following information. We will use this to determine whether you are eligible to
register as a permanent or temporary resident for free treatment on the NHS and eligible to
complete a GMS1 or GMS3 registration form or whether you should have a private registration
and be subject to practice private charges
Full Name ………………………………………………………………………………..
UK Address ………………………………………..…………………………………………
Home Address Overseas ………………………………………………………………………
Date of Birth………………………………………………..
Are you here on holiday (this includes long visits to family and friends)?
Yes / No
How long have you been living in the UK?
……….months / years
For how long will you be staying in the UK?
……….months / years
Part 1- Please provide one document for each of the appropriate sections below:
1. Passport & Visa (if there is one)
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2. European Health Insurance Card (if available)
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3. Right to stay in the UK, if from outside the EEA
 Identity papers from the Home Office – showing right to remain in the UK
 Proof of attendance at student course,
lasting more than six months in the UK
 Proof of attendance at UK government-sponsored student course,
lasting less than six months in the UK
 Entry clearance document (stamped)
 Current residence permit (stamped)
 Work permit
 Other proof of working in the UK for more than 6 months
 Ancestral Visa
 Birth Certificate
4. Evidence of your address (Your name & address must appear on the form)
 Local authority rent card
 Paid utility bills
 Bank/building society cards/statements
 National Insurance number card
 Current employment payslip
 Letter from Benefits Agency/benefit book/signing on card
 UK Pension book
 Official tax document
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5.: Insurance Details (As applicable, if seeking private registration)
I hereby authorise the GP Practice, or its authorised agents, to make enquiries with my insurers to
confirm the extent of, and the limits to, my health insurance policy. My insurance details are:
Insurers Name………………………………………………………………………………………..
Insurers Address……………………………………………………………………………………..
Post Code………………………Telephone number..……………………………………………..
Policy number..………………………Authorisation number……………………………………..
Benefits Administrator……………………………………………………………………………..
Notwithstanding the provisions of my personal undertaking, I agree to assign to the GP Practice
any of my rights to be paid for private patient charges by my insurers in respect of the current
episode of treatment provided. Should there be any shortfall in payment by the insurer I
understand that and agree to accept full liability. I also unreservedly authorise disclosure of any
medical notes including the provision of copies thereof to my insurer as part of their claim and
payment processing requirements.
Declaration: (To be signed whether applying for private or NHS patient registration)
I have read and understood the reasons I have been asked to complete this form, and agree to be
contacted by the GP practice to confirm any details given above. I agree that the relevant official
bodies can be contacted to verify any statement I have made, should this be necessary. The
information I have given on this form is correct to the best of my knowledge, I understand that if I
knowingly give false information or deliberately withhold information then further action may be
taken against me. This may include referring the matter to the National Counter Fraud Service in
Wales or the BCUHB Local Counter Fraud Specialist Team. Further, I understand that monies
which may apply and be due under the GP private patient tariff would be payable and in the event
of non-payment would be subject to a recovery action by the GP practice. I understand that should
my registration be accepted on the NHS all primary care treatment would be free and understand
that Overseas Visitor patients maybe subject to charges for certain services provided by NHS
hospitals under the Welsh Government hospital charging regulations. I understand I have a duty
to report to the hospital reception a permanent overseas residential address in addition to residing
at any UK temporary address.
Signed by: …………………………………………………..Date:………………………………
or on behalf of: ……………………………………………(Child under the age of 16 years)
Important: Please read carefully before signing this form
NHS hospital treatment is not free to all and all NHS bodies have a legal duty to establish
entitlement. If it is deemed necessary by the GP Practice, the information you provide will be
passed to the Home Office Immigration Compliance/Enforcement (HOIC/E) for ascertaining your
immigration status, which may effect your eligibility for free NHS hospital treatment. The HOIC/E
is responsible for securing the UK border and controlling migration for the benefit of the UK. The
information provided will be used and retained by the HOIC/E for its functions, which include
enforcing immigration controls overseas, at the ports of entry and within the UK. The HOIC/E may
also share this information with other law enforcement organisations and authorise debt recovery
agents for purposes including national security, investigation and prosecution of crime, and
collection of fines and civil penalties. If you fail to pay for NHS treatment for which charges have
been levied, it may result in a future immigration application to enter or remain in the UK being
denied. Necessary (non-medical) personal information may be passed via the Welsh Government
to the HOIC/E for this purpose.