Registering with us online

New Patient Registration

If you live within a 5 mile radius of Greyfriars Surgery, then you are welcome to register with us. To register please complete the online form. You will need to provide us with photographic I.D and a letter with your name and address on it (e.g. driving license/passport and utility bill)

Title: Required

First Name: Required

Surname: Required

Previous Surnames:

Date of Birth: Required

Gender: Required

Town and Country of Birth: Required

NHS Number:

Address: Required

Address 1

Address 2

City

Country

County

Postal Code

Home Telephone:

Work Telephone:

Mobile Number:

Email:

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

Your previous address in the UK

Address 1

Address 2

City

Country

County

Postal Code

Name of previous GP practice while at that address:

Address of previous GP practice:

Address 1

Address 2

City

Country

County

Postal Code

If you are from abroad.

Your first UK address where registered with a GP:

Address 1

Address 2

City

Country

County

Postal Code

If previously resident in UK, date of leaving:

Date you first came to live in the UK

Were you ever registered with an Armed Forces GP:

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas:

Regular

Reservist

Veteran

Family Member (Spouse, Civil Partner, Service Child)

Address before enlisting:

Address 1

Address 2

City

Country

County

Postal Code

Service or Personnel Number:

Enlistment Date:

Discharge Date (if applicable):

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*

* Not all doctors are authorised to dispense medicines

Do you live more than 1.6km in a straight line from the nearest chemist?:

Would you have serious difficulty in getting them from a chemist?:

NHS Organ Donor registration

The law has changed so that you now need to opt out if you do not want to become a Donor. It is important that you talk to your family about your organ donation decision as they will be asked to support your decision. If you are undecided or do not want to become an organ donor please contact the NHS Organ Donation website at www.organdonation.nhs.uk or 0300 123 23 23.

NHS Blood Donor registration

All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.

Would you like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood?:

Have you given blood in the last 3 year?:

My preferred address for donation is: (only if different from above e.g. your place of work)

Address 1

Address 2

City

Country

County

Postal Code

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

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 select on 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

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

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

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.

Do you have a non-UK EHIC or PRC?:

Country Code:

Name:

Given Names:

Date of Birth:

Personal Identification Number:

Identification number of the institution:

Identification number of the card:

Expiry Date:

PRC validity period from

PRC validity period to:

Do you have a 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):

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.

About You

Height:

Weight:

Marital Status:

Occupation:

If employed or self-employed, please provide your job title:

Ethnicity:

What is your first spoken language?:

Are you an English Speaker?:

Select any of the following service you wish to sign up to:

Answer Machine Messaging

Text Appointment Reminders

Patient Reference Group

Online Services

EPS

By agreeing to the sign up of online services, you are agreeing to the surgery sending your online login details through the post, once you are registered.

If you wish to nominate a Pharmacy provide the Pharmacy name here:

Carer/ Care Information

Do you care for anyone?:

If yes, please provide their relationship to you?:

Do you have a carer?:

Please provide any additional details you wish here:

For Women Only

What was the date of your last smear?:

Was the smear normal?:

Smoking Information

Select the best description for you?:

If ex-smoker when did you stop smoking:

If a current smoker, how many do you smoke a day. If you smoke a pipe or rolling tobacco provide how many ounces a week:

If you are currently smoking: Smoking can lead to many complications within your body including heart/breathing problems and cancer. One You Lincolnshire offer a smoking cessation service. To contact them, please call 01522 705162.

Medical History

Operations:

On-going Illnesses:

Allergies:

Immediate Family History (Past or Current)

If any of your family members have the following conditions please provide the family member and age of diagnosis (if known)

Angina/ Heart disease Under 60 Years Old:

Stroke:

Diabetes:

Asthma:

Alcohol

How often do you have 8 drinks (for men) / 6 drinks (for women) or more, on one occasion?: Required

How often in the last year have you not been able to remember what happened when drinking the night before?: Required

How often in the last year have you failed to do something that was expected of you because of drinking?: Required

Has a relative/friend/doctor/health worker been concerned about drinking or advised you to cut down?: Required

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Greyfriars Surgery South Square, Boston, Lincolnshire , PE21 6JU. Required

I consent

I agree to the privacy policy

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Registering with us online

New Patient Registration

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

If you are from abroad.

Were you ever registered with an Armed Forces GP:

If you need your doctor to dispense medicines and appliances*

NHS Organ Donor registration

NHS Blood Donor registration

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

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

About You

Carer/ Care Information

For Women Only

Smoking Information

Medical History

Immediate Family History (Past or Current)

Alcohol

Privacy Protection

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