New Patient Registration

If you would like to register with the practice please use this form.

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

Please be aware that any replies from the surgery may appear in your Junk Inbox.

Patient's Details

Please include any middle names.
Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
Where do you wish to be registered at?
Do you live more than one mile from a chemist?
Do you wish to be a dispensing patient?
Please see your local pharmacies.
We are unable to dispense to you, please see your local pharmacies.

Nationality

Do you need the assistance of a translator during consultations with the clinical team?

Emergency Contact

Third Party Consent

I hereby authorise:
To discuss my care and medical records and act on my behalf in relation to the healthcare I receive from Fakenham Medical Practice.

I also fully consent to Fakenham Medical Practice disclosing to the person named above any information including personal data held by Fakenham Medical Practice for the purpose of providing this service.

Please update my records accordingly. I will notify Fakenham Medical Practice should I change my mind.

Allergies

Previous Details

Please include postcode.

If you are from abroad

Registering with the NHS for the first time in the UK
Please use this date format: DD/MM/YYYY.

If you are returning from abroad

Previously been registered with the NHS in the UK
Please use this date format: DD/MM/YYYY.
Please use this date format: DD/MM/YYYY.

Supplementary Questions

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.

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

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

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.

British Military Forces

Have you served in the British Military Forces? (For any period of time)
Do you give your consent for this to be annotated on your medical record?
Please bring to the surgery your FP13 form after registering.

Carers

Would you like to receive a carers pack which contains useful local information?