PRF1 – Registration Form PRF1 – Registration Form Step 1 of 5 20% How to register with a GP surgeryYou should: •use a ‘tick’ or ‘x’ for boxes where necessary •complete all sections that apply to you or the person you are registering •provide as much information as possible •use BLOCK CAPITALS •if you cannot answer a question or it does not apply write ‘Not applicable’ or ‘N/A’ •only use black or blue ink •ask at the reception desk of the surgery you want to register with if you need help completing this formWhich sections should be completed? •Part A – all sections that apply. •Part B – this section is optional, but will help the GP provide the best care. •Part C – only complete these sections if you do not normally live in the UK. You may be contacted by the GP surgery if you do not complete all the relevant sections.Register online It is quick and secure to register with a new GP surgery online. Check the website of the surgery you want to register with for a link for the ‘Register to a GP surgery’ service. PART ATry to provide as much information as possible. If a question does not apply to you or the person you are registering write ‘Not applicable’ or ‘N/A’.Section 1 – Who is registering?Are you registering Yourself (Go to Section 2 – Patient details) Someone else Your Name First Optional Last Optional Your relationship to the person you are registering OptionalYour contact phone number OptionalYou can help save lives as a blood or organ donor. Become someone’s lifeline. Visit www.nhsbt.nhs.uk/lifeline or call us on 0300 123 23 23. Section 2 – Details of patient registeringName Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Middle Last Date of Birth DD slash MM slash YYYY What is your sex as recorded on your NHS record? Female Male Intersex Not specified or known NHS number (if you have it) OptionalVillage, town or city of birthCountry of birthCurrent address Street Address Address Line 2 Postcode What postcode did you give to the last GP surgery you registered with?Name and address of UK GP surgery you registered with Street Address Optional Address Line 2 Optional Postcode Optional Have you ever lived somewhere else in the UK? Yes No Last address in the UK Street Address Address Line 2 Postcode The NHS and your GP surgery can use these details to call, text or email you about health care services. All phone numbers must be registered in the UK.Home phone number OptionalMobile phone number OptionalEmail address Optional Name of emergency contact OptionalPhone number of emergency contact OptionalTheir relationship to you OptionalName of next of kin OptionalPhone number of next of kin OptionalTheir relationship to you OptionalSection 3 – Patients under 18 yearsFor children under 12 months onlyWhere were they born? England Optional Isle of Man Optional Northern Ireland Optional Wales Optional Scotland Optional Outside the UK Optional Address Street Address Optional Address Line 2 Optional Postcode Optional For patients under 18 yearsDo you attend any of the following? School Optional Nursery Optional Home school Optional None of these Optional Are any of these involved in your care? Hospital specialist Optional Health worker Optional Social worker Optional None of these Optional Address Street Address Optional Address Line 2 Optional Postcode Optional Have you had all your routine vaccinations? Yes Optional No Optional Don’t know Optional Did you get your routine vaccinations in the UK? Yes Optional No Optional Don’t know Optional Section 4 – Additional information1. What is your ethnic group?Choose one section from A to E, then tick one box to best describe your ethnic group or background.(A) White English, Welsh, Scottish, Northern Irish or British Optional Irish Optional Gypsy or Irish Traveller Optional (C) Asian or Asian British Indian Optional Pakistani Optional Bangladeshi Optional Chinese Optional Any other White background OptionalAny other Asian background Optional(B) Mixed or multiple ethnic groups White and Black Caribbean Optional White and Black AfricanWhite and Asian Optional (D) Black/African/Caribbean/British African Optional Caribbean Optional Any other Mixed or Multiple ethnic background OptionalAny other Black, African or Caribbean background Optional(E) Other ethnic group Arab Optional Prefer not to say Optional Any other ethnic group OptionalHave you registered with a UK GP before? Yes Optional No Optional If you have moved to the UK, what date did you arrive? Optional DD slash MM slash YYYY Have you ever served in the UK Armed Forces or were you ever registered with a Ministry of Defence GP in the UK or overseas? Yes Optional No Optional Prefer not to say Optional If you were given a FMED133A form (sometimes called an FMED1 form) when you left the UK Armed forces, you should give this to your GP surgery.Do you need an interpreter for your appointments? Yes Optional No Optional What language? Optional British Sign Language (BSL) Optional Are you a carer? Yes Optional No Optional What is your relationship to your carer? OptionalWhat is your relationship to the person you are caring for? OptionalWhat type of carer are they? Young carer, under 18 Optional Paid as a job Optional Unpaid, but may get benefits Optional Foster carer Optional What type of carer are you? Young carer, under 18 Optional Unpaid, but may get benefits Optional Paid as a job Optional Foster carer Optional Do you have a carer? Yes Optional No Optional Carer’s contact telephone number OptionalWhat pharmacy do you want your prescriptions sent to? Pharmacy address Optional Address Line 2 Optional Postcode Optional You can sometimes collect your prescription items from your GP surgery instead of having to go to a pharmacy. Your surgery may discuss this with youDo you live more than 1 mile from your nearest pharmacy? Yes Optional No Optional Would you have serious difficulty getting medicines or appliances from your nearest pharmacy? Yes Optional No Optional Do you want important information from your GP record to be available to other health and care professionals?Your GP surgery needs permission to share important information from your GP record. This is called a Summary Care Record (SCR). Your SCR can only be shared with health and care staff across England who are providing you with direct care. It gives them access to vital information from your GP record. Yes, share a Summary Care Record with additional information Includes details of your medicines, allergies, adverse reactions and additional information, which includes details of any significant illnesses and health problems, operations and vaccinations Optional Yes, share a Summary Care Record without additional information Includes details of your medicines, allergies and adverse reactions only Optional No, do not share a Summary Care Record Details of your medicines, allergies, adverse reactions and any additional information will not be shared with anyone involved in your direct care Optional PART BYou do not have to complete this section. But any information you do give will help the GP give you the best care.Section 5 – Patient healthHave you ever had any of these conditions? Alzheimer’s disease or dementia Optional Asthma Optional Cancer Optional Diabetes Optional Epilepsy Optional Heart disease Optional High blood pressure (hypertension) Optional Stroke Optional Thyroid disease Optional What best describes you? I smoke Optional I used to smoke Optional I have never smoked Optional Prefer not to say Optional On average, how many cigarettes do you smoke a day? OptionalWhat date did you stop smoking? Optional DD slash MM slash YYYY How often do you drink alcohol? Never Optional Monthly or less Optional 2 to 4 times a month Optional 2 to 3 times a week Optional 4 or more times a week Optional Prefer not to say Optional How many units of alcohol do you drink on a typical day when you are drinking?1 pint of 4% beer is 2.5 units. a small 125ml glass of wine is 1.5 units and a 25ml shot of spirits is 1 unit.Units OptionalHow often have you had six or more units of alcohol on a single occasion in the last year? Never Optional Less than monthly Optional Monthly Optional Weekly Optional Daily or almost daily Optional Prefer not to say Optional What is your weight?Kilograms OptionalStone OptionalPounds OptionalWhat is your height?Centimetres OptionalInches OptionalUntitled OptionalAllergies OptionalMental health conditions OptionalDisabilities OptionalOther medical conditions OptionalGive details of any medication you are taking OptionalAre any of these repeat prescriptions? Yes Optional No Optional Do you or your carer need to be communicated in an accessible format?For example, braille, audio, large format or EasyRead.Tell us what you need OptionalDo you or your carer need any reasonable adjustments to make your visit to the GP surgery accessible?For example, an audible or visual alert in the waiting room, access to a hearing loop or the support of a note taker.Tell us what you need Optional PART CSection 6 – Patients from abroadComplete this section if you are: • visiting the UK and do not normally live here. • currently living in the UK, but do not think of it as your permanent country of residence. For example, you are studying here or have come to the UK as part of your job. • a permanent resident in the UK and receive a pension or benefit from a European country.Information on eligibility to free care outside the GP practice Anyone can register with a GP practice and receive free medical care from that practice. However, should you be referred for treatment outside the practice or need unplanned care, for example at a hospital, charges may apply if you are a visitor or temporary resident. Some groups of visitors or temporary residents are eligible to receive this care free of charge. Documentation may be required to demonstrate eligibility. Examples of those eligible include: • refugees, asylum seekers, those receiving certain forms of state support • suspected or confirmed victims of modern slavery and human trafficking • temporary residents with a valid visa of over 6 months. You may have paid the immigration health surcharge with your visa application. Note that assisted conception services remain chargeable to this group • visitors from the EEA will need to provide their EHIC (European Health Insurance Card), which covers immediately necessary unplanned treatment, or a S2 form which covers planned treatment. Additionally, some services are free of charge to all visitors, including diagnosis and treatment for infectious diseases and sexually transmitted infections. Immediate necessary care, maternity care and other urgent care that cannot wait until a chargeable visitor’s departure from the UK will not be withheld or delayed due to charges. But non-urgent treatment will not be given until full payment is received. More information can be found in the patient leaflet available from the GP practice.Select the statement that applies to you I understand I may have to pay for NHS treatment outside of the GP practice. Optional I do not have to pay for NHS treatment outside of the GP practice and have documents to prove this. Optional I do not know if I have to pay for treatment. Optional Giving us this information means that if you need NHS care outside the GP practice and you are entitled to that care without charge, it will be easier for you to demonstrate this entitlement. We’ll use the information to establish your chargeable status in order to recover NHS costs from countries responsible for your healthcare where applicable. This will not impact your entitlement to register with the GP practice or to receive free GP services.Tick one of the following I have an S1 form issued by an EU or EEA member state Optional I am in receipt of a European pension or benefit Optional I am entitled to an EHIC card, but I do not have one Optional I am in the UK as part of my employment Optional I have an EHIC card issued by an EU or EEA member state Optional None of these Optional Enter details from your EHICCountry code OptionalPersonal identification number OptionalName OptionalIdentification number of the institution OptionalGiven name OptionalIdentification number of the card OptionalDate of Birth Optional DD slash MM slash YYYY Date Optional DD slash MM slash YYYY How will your EHIC and S1 data be used?By using your EHIC for NHS treatment costs your EHIC 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 or S1 information will be shared with Business Service Authority for the purpose of recovering your NHS costs from your home country.