AMC New Patient Registration Form (GMS1) and Questionnaire

Fields marked "REQUIRED" are compulsory. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Your details will be held at the surgery for a limited period of time. You are required to present in person to sign your registration form and provide proof of your address. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 22/05/2024

  • Patient's Details

    Date of Birth
    For example, 15 3 1984
    Sex (optional)

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

  • If you are from abroad

    If previously resident in UK, date of leaving (optional)
    For example, 15 3 1984
    Date you first came to live in UK (optional)
    For example, 15 3 1984

  • Were you ever registered with an Armed Forces GP

    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.

    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 (optional)
    Enlistment Date (optional)
    For example, 15 3 1984
    Discharge date (if applicable) (optional)
    For example, 15 3 1984

  • Complete Registration

    *Not all doctors are authorised to dispense medicines

    If you need your doctor to dispense medicines and appliances* (optional)
    Signature (optional)

  • What is your ethnic group?

    Please tick one box that best describes your ethnic group or background from the options below:

    White (optional)
    Mixed (optional)
    Asian or Asian British (optional)
    Black or Black British (optional)
    Other ethnic group (optional)
    Not stated (Not Stated should be used where the PERSON has been given the opportunity to state their ETHNIC CATEGORY but chose not to (optional)

  • SUPPLEMENTARY QUESTIONS | 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: (optional)
    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. (optional)

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

    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 the GP practice, including at hospital).

    Do you have a non-UK EHIC or PRC? (optional)
    Date of Birth (optional)
    For example, 15 3 1984
    Expiry Date: (optional)
    For example, 15 3 1984
    a) From: (optional)
    For example, 15 3 1984
    b) To: (optional)
    For example, 15 3 1984
    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. (optional)

  • 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.

  • New Patient Questionnaire

    Please fill out this section as best to your ability as this assists your registration process ensuring the most up to date information is on your records. 

     

     

    Are you housebound?
    Please select preferred method of contact
    Are you a carer?

  • Repeat Medications

    Please ensure you have at least 1 months suppluy of medication from your previous surgery as it can take a couple of weeks to your medical records to fully transfer over. 

     

  • Summary Care Record

    Summary Care Records are created for all new patients unless you opt out. 

    Summary Care Record is an electronic record of important patient information, created from GP medical records. It can be seen and used by authorised Staff in other areas of the health and care system involved in the patient'd direct care  e.g A&E, 111.

    Please tick one Option
    Record Sharing (with other organisations e.g. District Nurses, Community Podiatry, Dieticians, Diabetes services etc)

  • Medical Conditions

    Your named accountable GP is Dr Ghosh. Your GP is responsible for your overall care at the practice. Please be aware you may be asked to see an alternative GP due to capacity and staff sickness.

     

    Would you like a new patient health check?
    What is your current smoking status?

  • Alcohol intake

    Please tick the fits responses that fit best.

    How often for you have 8 (men) / 6 (women) or more units of alcohol on one occasion?
    How often in the last year have you not been able to remember what happened when drinking the night before?
    How often in the last year have you failed to do what was expected of you because of drinking?
    Has relative / friend / doctor / health worker been concerned about your drinking or advised you to cut down?

  • Patient Participation Group (PPG)

    The purpose of the PPG is to review feedback from service users. We meet a few times a year to ensure that patients and carers are involved in decisions about the range, shape and quality of services provided by our practice. 

    Would you like to join our PPG?
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