How to register – Gas House Lane Surgery

Please note due to staff shortages there may be a delay of up to 14 working days for a registration to be completed

We welcome new patients to our practice. Patients can register at the practice if they live within the practice boundary by completing a registration form. You can ask for a form at our reception or simply fill out the form online by clicking below. You will also be asked to complete a New Patient Questionnaire, and once completed we request that all new patients have a health check with the Practice Nurse within the first month of joining the practice. Due to coronavirus we may be unable to offer a health check with one of our practice nurses at the moment, however, if you do have a concern about your health you can book an appointment with one of our doctors once you are registered. As a practice we aim to get the registered with ourselves within 5 working days.

Check if you live inside our practice boundary

Please check to make sure you live within our practice. You can do this by simply entering your postcode below. Please note, if your address is outside of this boundary the practice will be unable to accept your registration.

GMS1 registration form England

Patient's details

Do you live inside the practice boundary?(Required)

Yes I have checked my postcode and I do live inside the practice boundary.

No I do not live inside the boundary

You do not live inside our practice boundary. Do NOT complete this form as we will NOT be able to register you.

Title(Required)

Mrs

Miss

Other

Please add your title

Name(Required)

First names Surnames

Previous surnames

NHS Number(Required)

Get help to find your NHS number online

Date of birth(Required)

Day

Month

Year

Town of birth(Required)

Country of birth(Required)

Home address(Required)

Postcode(Required)

Telephone number(Required)

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

Your previous address in UK

Name of previous GP practice while at that address

Address of previous GP practice

Registration from abroad

Are you registering from abroad?

Yes

Your first UK address where registered with a GP

If previously resident in UK, date of leaving

Day

Month

Year

Date you first came to live in UK

Day

Month

Year

Armed Forces Registration

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.

Were you ever registered with an Armed Forces GP?

Yes

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

Postcode

Service or Personnel number

Enlistment date

Day

Month

Year

Discharge date (if applicable)

Day

Month

Year

If you need your doctor to dispense medicines and appliances*

*Not all doctors are authorised to dispense medicines

I need my doctor to dispense medicines and appliances(Required)

Yes

I live more than 1.6km in a straight line from the nearest chemist

Yes

I would have serious difficulty in getting them from a chemist

Yes

Ethnic group

Please select one answer that best describes your ethnic group or background from the options below(Required)

White - British

White - Irish

White - Irish Traveller

White - Traveller

White - Gypsy/Romany

White - Polish

White - Other

Mixed background - White and Black Caribbean

Mixed background - White and Black African

Mixed background - White and Asian

Other Mixed background

Asian or Asian British - Indian

Asian or Asian British - Pakistani

Asian or Asian British - Bangladeshi

Other Asian background

Black or Black British - Caribbean

Black or Black British - African

Black or Black British - Somali

Black or Black British - Nigerian

Other Black background

Other ethnic group - Chinese

Other ethnic group - Filipino

Other ethnic group

Not stated (Not Stated should be used where the PERSON has been given the opportunity to state their ETHNIC CATEGORY but chose not to)

Please state your ethnic group or background

Supplementary questions

These questions and the patient declaration are optional and your answers will not affect your entitlement to register or receive services from your GP.

Are you ordinarily resident in the UK(Required)

Yes

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 one of the following options(Required)

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 (“the Surcharge”), when accompanied by a valid visa. 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.

A parent/guardian should complete the form on behalf of a child under 16.

I agree to the statement above

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

You only need to 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.

I live in another EEA country, or I have moved to the UK to study or retire, or I live in the UK but work in another EEA member state.

Yes

Do you have a non-UK EHIC or PRC?(Required)

Yes

If yes, please enter details from your EHIC or PRC below:

3: Name(Required)

Country Code(Required)

4: Given Names(Required)

5: Date of Birth(Required)

Day

Month

Year

6: Personal Identification Number(Required)

7: Identification number of the institution(Required)

8: Identification number of the card(Required)

9: Expiry Date

Day

Month

Year

PRC validity period (a) From:

Day

Month

Year

PRC validity period (b) To:

Day

Month

Year

S1 Form

Please tick if you have an 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).

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.

Yes I have an S1 form

New Patient Questionaire

Email address (if you're happy to recieve communication when appropraite via email)

Next of kin(Required)

Relationship to you(Required)

Contact number(Required)

Carers

A Carer is someone, who, without payment, provides help and support to a partner, child, relative, friend or neighbour, who could not manage without their help. This could be due to being elderly, physical or mental illness, addiction or disability. We would be grateful if you could complete the following questions for the Practice Carer’s Register. The register enables the practice to proactively manage carer’s needs with the practice and to consider the provision of services to carers. The practice will also ensure that all patients who are carers are informed of and supported in joining the local carer’s link.

Are you a carer?(Required)

Yes - Informal/Unpaid carer

Yes - occupational/Paid carer

Are you being cared for?(Required)

Yes

Alcohol consumption - How many units of alcohol do you consume in a week?

Approximately - 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits. 1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units. Find out more about alcohol units on the NHS website

Do you drink alcohol?

Yes

How many units per week?(Required)

Smoking

What is your smoking status?(Required)

Never smoked

Ex-smoker

Smoker

How many cigarettes did/do you smoke per day?

For example 5 / 10 / 15 / 20 / more than 20

Do you use an e-Cigarette?(Required)

Ex-user

Yes

If you smoke, would you be interested in our stop smoking clinic?

For further information please see: www.nhs.uk/smokefree

Yes

Exercise

Do you exercise regularly?

Yes

If so, how what type of exercise and how often do you do this?

Height

Weight

Information about you

Ethnicity(Required)

White (UK)

White (Irish)

White (Other)

Black Caribbean

Black African

Black Other

Bangladeshi

Indian

Pakistani

Chinese

Other

If other, please specify

Religion(Required)

Church of England

Catholic

Other Christian

Buddhist

Hindu

Muslim

Sikh

Jewish

Jehovah's Witness

No Religion

Other

If other, please specify

Communication needs

What is your first language?(Required)

Do you need an interpreter?

Yes

Language of interpeter

Do you have any specific communication needs?

Yes

Please select your communication needs below

Hearing aid

Lip reading

British sign language

Large print

Makaton sign language

Braille

Guide dog

Do you have a learning disability?(Required)

Yes

If you live more than 1 mile (as the crow flies from a pharmacy, you are eligible to use to GP surgeries medication dispensary for you prescriptions.(Required)

Please indicate if you live in one of the following areas, all of which are eligible for this service: Barmoor, Bothal, Catchburn, Causey Park, Clifton, Collingwood manor, Earsdon, Earsdon East Forrest, East benbridge, East Edlington, Ellington, Eshott, Espley, Fairmoor, Fairmoor Meadows, felton, Fenrother, Fulbck, Gallowhill, Gubeon, Hartburn, Hartburn Bridge, Hebron, Hepscott, Hepscott Park, Kirkley, Linton Colliery, Longframlington, Longhirst, Longhorsley, Longwitton, Low Heighley, Meldon,Meldon Park, Middleton, Mitford, Netherwiton, Newton underwood, Northgate, Ogle, Pigdon, Red Row, Seaton Burn, Shadfen, St Andrews Gardens, Stannington, St Mary park, St Marys Hospital, Netherton Park, Stanton, Throphill, Thropton, Tranwell, Tranwell Wood, Titlington, West Benbridge, West Thirston, Whalton, Wingates

Yes I'm Eligible

No I'm not eligible

Please select which pharmacy you would like your medication to be sent to?(Required)

Boots The Mount

Boots Bridge Street

The Health Hut

Morpeth Pharmacy (Wellway)

Stobhill Pharmacy

Wellway Pegswood

Other

If you have selected other, please specify the name and postcode of the chemist

Privacy

Summary care record(Required)

All patients have the choice of having a Summary Care record (SCR). The SCR will contain important information about any medicines you are taking, allergies you suffer from and any bad reactions you have had. Giving healthcare staff access to this information can prevent mistakes being made when caring for you in an emergency or when your GP practice is closed. Your SCR will also include your name, address, date of birth, and your unique NHS number to help identify you correctly.

I DO want a summary care record uploaded

I DON'T want a summary care record uploaded

If you do want a summary care record, please tick which consent you would like to give

Express consent for medication, allergies and adverse reactions ONLY

Express consent for medication, allergies, adverse reactions and other additional information

Sharing Out(Required)

Do you consent to the sharing of data recorded here with other organizations within the NHS that may care for you?

Yes - share data with other organsiations

No - do not share any data recorded here

Sharing In(Required)

Do you consent to the viewing of data by this organization that is recorded at other care services that may care for you? (when you have agreed with that organization to make information sharable)

Consent Given

Consent Refused

Not for urgent medical help(Required)

I agree that I am not submitting this for urgent medical help

Consent(Required)

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.

I agree to the privacy policy.

Name

This field is for validation purposes and should be left unchanged.