Please complete and tick boxes as appropriate.
*Not all doctors are authorised to dispense medicines
I want to register my details on the NHS Organ Donor Register as someonewhose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply
Signature confirming my agreement to organ/tissue donation
For more information, please ask at reception for an information leaflet or visit the website www.organdonation.nhs.uk, or call 0300 123 23 23.
I would like to join the NHS Blood Donor Register as someone who may be contacted and would be preferred to donate blood.
For more information, please ask for the leaflet on joining the NHS Blood donor Register.
My preferred address for donation is: (only if different from above, e.g., your place of work)
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 tick one of the following boxes:
A parent/guardian should complete the form on behalf of a child under 16
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.
NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS
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?
If yes, please enter details from your EHIC or PRC below:
4: Given Names
5: Date of Birth
6: Personal Indemnification Number
7: Identification number of the institution
8: Identification number of the card
9: Expiry Date
PRC validity period
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.
Thank you! Your submission has been received!
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