Provide the details below to register with the Practice. A member of staff may need to telephone you to confirm certain aspects of your registration.
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.
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.
If yes, please enter details from your EHIC or PRC below:
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.
Please indicate which immunisations the child has had. The exact dates they were carried out and whether they were done at the previous doctor’s surgery, a health authority clinic or elsewhere. Details can be found in the back of the red Child Development book.
Please complete below to indicate if any of your family have had any of the following conditions. Please specify if the family member was father, mother, brother, sister or another relative.
If you would like to register for the online booking service please obtain an online registration consent from our reception.
You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care.
Your options are outlined below; please indicate your choice:
The data held in your GP medical records is shared with other healthcare professionals for the purposes of your individual care. It is also shared with other organisations to support health and care planning and research. If you do not want your personally identifiable patient data to be shared outside of your GP practice for purposes except your own care, you can register an opt-out with your GP practice. This is known as a Type 1 Opt-out.
This decision will not affect individual care and you can change your choice at any time, using this form. This form, once completed, should be sent to your GP practice by email or post.
Type 1 Opt-outs may be discontinued in the future. If this happens then they may be turned into a National Data Opt-out. Your GP practice will tell you if this is going to happen and if you need to do anything.
More information about the National Data Opt-out can be found on the main registration page.
If you are filling in this form on behalf of a dependent e.g. a child, the GP practice will first check that you have the authority to do so. Please complete the details below:
Your decision
I do not allow my identifiable patient data to be shared outside of the GP practice for purposes except my own care.
OR
I do not allow the patient above’s identifiable patient data to be shared outside of the GP practice for purposes except their own care
Or
I do allow my identifiable patient data to be shared outside of the GP practice for purposes beyond my own care.
I do allow the patient above’s identifiable patient data to be shared outside of the GP practice for purposes beyond their own care.
Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.
All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
I consent to my information being used for the purposes described above and wish to submit this online form to The Farley Road Medical Practice • Farley Road, 53 Farley Road, South Croydon, Surrey, CR2 7NG.
Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.
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