New Patients

Online New Patient Registration

Registering at Lake Road Practice is quick and simple. Please complete the form below as fully as possible. Once it has been submitted please allow 1 week for your new patient registration to be processed.

A PARENT/GUARDIAN SHOULD COMPLETE THE FORM ON BEHALF OF A CHILD UNDER 13.

CHILDREN OVER 13 SHOULD COMPLETE THE FORM THEMSELVES

About You

Please include all your given names.
Please use this date format: DD/MM/YYYY.
If not born in the UK. Please use this date format: DD/MM/YYYY.
Please include postcode.
Please include postcode.
Please ensure that your email address is correct as this is how you will be notified of a reply.

Medical Details

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

Women Only

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

Alcohol Questionnaire

This is one unit of alcohol:

And each one of these, is more than one unit:

Section C Questions

This will be automatically counted for you.

If you have scored more then 7 please complete the questions below:

* If yes, please note that your score will determine if you are referred to another service

Information Sharing

Pharmacy Nomination

We can now send your prescriptions to the pharmacy electronically for you, reducing the amount of paper used and making collecting your prescription easier for you. Please fill in the details below so that we can add them to the system. We will clear any previously nominated pharmacy as part of our registration process so you will need to complete the section below, even if you already have a nominated pharmacy.

Ethnicity

Please include name and relationship.
Parent/guardian for under 13s
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.

NHS