Stethoscope

Old Road | Tean | Stoke-on-Trent | ST10 4EG | telephone: 01538 722 323
For the Dispensary telephone: 01538 722 215

Blythe Bridge Primary Health Care

Tean Surgery

 

 

 

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Registration Form

Please note the following terms of use for online registration:

  • You should only send this form if you are sure you are eligible to join the practice
  • Sending this form will not automatically register you with the surgery, it will merely send the completed application for the surgery to process.
  • On your first visit to the surgery, you will be asked to sign the form and provide proof of address.
  • Sending the form does not guarantee you will be accepted on the practice register.
  • A copy of the completed form will be sent to the surgery and the email address you provide.

Personal Data

Please note that by using this form you will be sending personal information over the internet.  The form uses an encrypted connection with https SSL certificates, and every effort is made to keep this information secure. However, we cannot guarantee absolute privacy.  If you have any concerns about electronic submissions then you should use another method of registration.

It should be further noted that no personal information is stored on this website or any servers relating to it.  Once your form is submitted it will emailed to the surgery and all information will be deleted once that process is completed.

 

Online Family Doctor Patient Registration Form


    Patient's Details

    MrMrsMissMs

    MaleFemale


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





    If you are from abroad



    Were you ever registered with an Armed Forces GP


    n/aRegularReservistVeteranFamily Member (Spouse, Civil Partner, Service Child)


    Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.


    If you need your doctor to dispense medicines and appliances*

    I live more than 1.6km in a straight line from the nearest chemist

    I would have serious difficulty in getting them from a chemist

    *Not all doctors are authorised to dispense medicines


    Signatures

    Please select only one option:

    Signature of PatientSignature on behalf of patient


    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. Please tick the boxes that apply.

    Any of my organs and tissue

    OR

    Kidneys
    Heart
    Liver
    Corneas
    Lungs
    Pancreas

    Signature confirming my consent to join the NHS Organ Donor Register


    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 have given blood in the last 3 years

    Signature confirming my consent to join the NHS Blood Donor Register


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

    These questions are optional and your answers will not affect your entitlement to register or receive services from your GP.

    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.

    Please tick one of the following boxes:

    a) I understand that I may need to pay for NHS treatment outside of the GP practice
    b) 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
    c) I do not know my chargeable status

    A parent/guardian should complete the form on behalf of a child under 16.


    Non-UK European Health Insurance Card (EHIC)

    Complete this section if you live in another 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 of the GP practice, including at a hospital.

    n/aNoYes

    Please tick if you have an S1 (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.


    Your email address to receive a copy of the completed form

    This is for your benefit and is not included on the form sent to the surgery

     

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