For all new patient registrations, we require proof of identity and address documentation.
For more information regarding our practice please see the attached leaflet
Patient Registration Leaflet
Please note that ALL telephone calls made to and from the surgery are recorded for training and monitoring purposes.
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.
* Not all doctors are authorised to dispense medicines
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.
All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.
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.
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.
If yes, please enter details from your EHIC or PRC below:
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 an ex-smoker please answer the 2 following questions
Pint of regular beer/lager/cider 2 units
Alcopop or can of beer/lager/cider 1.5 units
Glass of wine (175 ml) 2 units
Single measure of spirits 1 unit
Bottle of wine 9 units
Please advise if any of your immediate family suffered from any of these conditions:
High blood pressure
Please indicate date last given for each of the following
If you are registered with a GP practice in England, you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past.
Information about your healthcare may not be routinely shared across different healthcare organisations and systems. You may need to be treated by health and care professionals who do not know your medical history. Essential details about your healthcare can be difficult to remember, particularly when you are unwell or have complex care needs.
Having a Summary Care Record can help by providing healthcare staff treating you with vital information from your health record. This will help the staff involved in your care make better and safer decisions about how best to treat you.
You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care.
If you chose not to answer the following question, a core Summary Care Record (SCR) will be created for you, which will contain only medications, allergies and adverse reactions.
Please choose one of the following options
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
Church Street Surgery
30a Church Street, Bishop's Stortford, Hertfordshire , CM23 2LY.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.