New Patient Registration

Due to issues with capacity – we are currently unable to accept registrations from patients who are already registered with a GP practice in the Hertford area.

We will continue to accept registrations from patients who have newly moved to the area.

To register a new patient you will need to live within our practice boundary.

If you would like to register with the practice please use this form. Please also complete a new form for any child you are registering under the age of 16 years.

Alternatively a form can be obtained from our reception.

Once you have completed the form you will need to come into the practice with one proof of ID and one proof of address, i.e. utility bill/bank statement dated within 4 weeks to complete your registration. Please allow at least two working days for us to process this form before presenting at the practice with your documents.

If you do not present yourself at the surgery with ID and proof of address within 28 days of submitting the form it will be destroyed and the process will have to start over.

Please allow a minimum of 2 weeks for your registration to be processed from the date you present to the practice with your ID. Until you are fully registered with us your existing practice is responsible for your care.

New Patient Registration

Patient's Details

Title *
Please use this date format: DD/MM/YYYY.
Gender *
How to find your NHS Number - Your NHS number is a 10 digit number, like 485 777 3456. It is on any letter you receive from the NHS.
To be verified by the Practice.
Any responses we send will go to this email address.
Can we contact you by text?
Can we contact you by email?

Ethnicity

Please specify the ethnic group you consider you belong to:
Do you speak English?
Do you read English?

Emergency Contact

Are they your Next of Kin?
Do you give us permission to discuss your medical records with them?

Allergies

Do you have any allergies?

Previous Details

Please include postcode.

If you are from abroad

Registering for the first time in the UK

Please use this date format: DD/MM/YYYY.

If you are returning from abroad

Previously been a resident in the UK

Please use this date format: DD/MM/YYYY.
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.

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. Alternatively for more information go to www.nhs.uk/visitingengland.

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 one of the following statements:

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.

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?
Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?

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.

S1 Form

Do you have an S1 Form?
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.

If you are returning from the Armed Forces

If you need your doctor to dispense medicines and appliances *

* not all doctors are authorised to dispense medicines

Carers

Do you have a carer?
Are you a carer for someone?
Do you give us permission to discuss your medical record with your carer?