New Patient Registration | Montgomery-House Surgery

If you would like to register with the Practice please use this form.

IT IS VERY IMPORTANT THAT YOU PROVIDE AS MUCH INFORMATION AS POSSIBLE

Once you have completed the form you will need to come into the Practice with one proof of ID and one proof of address to complete your registration (Driving Licence, Passport, Utility bill etc). For children we will need a copy of their birth certificate or passport so we can verify their name and date of birth.

Please allow 5 working days for us to process your registration before making a routine appointment – if you have an urgent issue, then please contact us. We will register you for Patient Online Services, and you will be able to get your log on details from our team.

All our new patients are invited to, and required to attend, a ‘new patient’ appointment. This is so that we can introduce you to our Practice, establish your current state of health, check your blood pressure and offer further services as appropriate. Once registered, please watch out for your invite and then respond.

Practice Area

You can register at the Practice if you live in our area. Please see our Practice Patient Boundary Map.

Please note that the Heyford Park development is outside our Practice area.

NHS Number

Please obtain your NHS Number from your old GP Practice if you don’t know it. We require this to ensure that you are registered correctly and that we can transfer your medical records to Montgomery-House Surgery.

Temporary Registration

If you are ill while away from home or if you are not registered with a doctor but need to see one you can receive emergency treatment from the local GP practice for 14 days. After 14 days you will need to register as a temporary or permanent patient.

Find out more about temporary registration

Overseas Visitors

For Guidance on overseas visitors please visit www.Gov.uk for further information.

If you have a EHIC card /PRC/S1, how will you 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.

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

Use of Texts, Emails and Messaging

Mobile – Texts: To improve our service to patients we send appointment and medical review reminders by text, and encourage patients to opt in to this.

For further information on our use of texts, emails and messaging, and the safeguards in place, please see our Information Technology page.

Dispensary & Prescriptions

We dispense directly to patients who live more than a mile (as the crow flies) from a community pharmacy; we currently dispense to 3,500 patients. To see if this applies to you please use our mapping tool. Please sign up to this service if applicable.

Our on-site dispensary is open between 08:30 and 18:00

Electronic Prescription Service (EPS)

We use the EPS. This means your prescription is sent electronically to whichever pharmacy you have elected to use, saving both time and cost as well as being more convenient for you.

Summary Care Record

A Summary Care Record is an electronic record used nationally across England and is available to authorised healthcare professionals who care for you in urgent or emergency situations . This might be if you are ill when you are away from home or when your GP surgery is closed. It is based on your GP record and contains key information to support emergency care such as: medicines you take; any allergies you have; or any bad reactions you have had to medicines. This is now created automatically for you. You can opt to include Additional Information, including significant medical history, medication, management of long term conditions, end of life care, immunisations and communication preferences (Sensitive information like fertility treatment STIs, pregnancy terminations etc are not automatically included unless you request them to be included). We recommend that you OPT IN to Additional Information being included in your SCR.

The Oxfordshire Care Summary is similar, but contains additional information for healthcare providers you may have need to use in Oxfordshire (e.g. A&E, Out of Hours doctor, District Nurse etc). We recommend that you OPT IN to this.

An information leaflet is available here for the Oxfordshire Care Summary

Patient Consent to Share Medical Information

For patients 16 years and over who wish to provide access to their medical information to a 3rd party such as a carer, family member or close friend, then a “Patient Consent – Share Medical Information” form is required. This can be printed from our website (see Practice Information) or is available from Patient Services.

Patient Online Services

By using our Patient Online Services you can make repeat prescriptions, or view any test results 24/7 on your mobile, tablet or PC. For more information click here. We recommend that you are signed up to this.

For Patients 14 years and older Proxy Access can be given to a 3rd Party by completing the “Patient Consent – Share Medical Information ONLINE” form. This can be printed from our Website (see Practice Information) or is available from Patient Services.

If you are human, leave this field blank.

Are you Registering a Child under 16 years? *

Yes

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

Help us trace you medical records by providing the following information

Previous address in UK: *

Please include postcode.

Name and address of previous GP: *

If you are from abroad

Are you visiting or moving to the UK from overseas? *

Yes

Your first UK address where registered with a GP:

Date you came to live in the UK:

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

If you are returning from abroad

Previously been a resident in the UK

Date you left the UK:

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

Date you returned to the UK:

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

Were you ever registered with an Armed Forces GP

Are you a military veteran? *

Yes

Are you returning from the Armed Forces? *

Yes

Address before enlisting:

Services or Personnel number: *

Enlistment date:

What is your ethnic group?

Nationality: *

Please specify the ethnic group you consider you belong to: *

Please state:

Do you speak English? *

Yes

Do you read English? *

Yes

Would you like a Foreign Language Interpreter to be arranged for your consultations? *

Yes

First Language: *

Overseas Visitors Accessing Healthcare in the UK

I am not ordinarily a resident in the UK

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.

Please select one of the following statements: *

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.

Signature

Print Name

On behalf of

Relationship to patient

Date

European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea

Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?

Yes

Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?

Yes

EHIC/PRC

Please enter the details from your EHIC or PRC below.

Country Code

3. Name

4. Given Names

5. Date of Birth

6. Personal Identification Number

7. Identification number of the institution

8. Identification number of the card

9. Expiry Date

PRC validity period - from:

PRC validity period - to:

S1 Form

Do you hold a S1 Form?

Yes - I have an S1 form (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?

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 Organ Donor registration

Organ donation in England is now an opt out system, so you can still decide whether or not you want to become an organ donor. For more information and to change your preferences, please visit: www.organdonation.nhs.uk

You can also update your preference through:

DVLA
GP surgery (via the GMS1 paper form only)
NHS Organ Donor Line
Boots Advantage Card
NHS Blood & Transplant paper registration form
NHS App

NHS Blood Donor registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323

Emergency Contact

Full Name: *

Relationship to you: *

Phone Number: *

Are they your Next of Kin? *

Yes

Do you give us permission to discuss your medical records with them in an Emergency at our discretion? *

Yes

For patients 16 yrs and over - for patients who wish to provide access to their medical information to a 3rd party such as a carer, family member or close friend, then a “Patient Consent – Share Medical Information” form is required. Please download the form and return this to the surgery.

Carers

Do you have a carer? *

Yes

Are you a carer for someone? *

Yes

Name of carer: *

Phone Number: *

Address: *

Do you give us permission to discuss your medical record with your carer? *

Yes

For patients who wish to provide access to their medical information to a 3rd party such as a carer, family member or close friend, then a “Patient Consent – Share Medical Information” form is required. Please download the form and return this to the surgery.

Prescriptions

If you live further than 1 mile from a community pharmacy you will be able to use our Dispensary to obtain your medication – this is known as being a “Dispensing Patient”

To see if this applies to you please use our Dispensary Eligibility mapping tool

Would you like to register for Electronic Prescription Service (EPS)? *

Yes

I would like to register my Electronic Prescription Service (EPS) with the following pharmacy. Please select “On-Site Dispensary” if using our Dispensary. *

Pharmacy Name: *

Pharmacy Address: *

Pharmacy Postcode: *

Summary Care Record and Oxfordshire Care Summary - your choice

Please note that these records are used only for the purpose of enabling informed care to be supplied directly to you as an individual.

You patient record is held securely and confidentially on the electronic system at your GP Practice. If you require treatment in another NHS healthcare setting such as an Emergency Department or Minor Injury Unit, those treating you would be better able to give you appropriate care if some of the information from the GP practice were available to them.

This information can now be shared electronically via:
1. The Summary Care Record: used nationally across England
2. The Oxfordshire Care Summary: used locally across Oxfordshire

In both cases, the information will be used only by authorised health care professionals directly involved in your care. Your permission will be asked before the information is accessed, unless the clinician is unable to ask you and there is a clinical reason for access.

A patient or guardian can request to opt out children under 16 ultimately it is the GPs decision whether to create the records or not, because of their duty of care to the child. If you are the parent or guardian of a child under 16 and feel that they are able to understand, then you should make this information available to them.

Are you happy for us to share this electronic information with clinicians in other NHS organisations who are involved in your care? If you would rather we didn't, we will put an entry on your record which will prevent your information from being shared.

In England a Summary Care Record (SCR) is automatically created for you unless you opt out. If you wish to opt out please contact the Practice.

Your choice for SCR Additional Information *

I do want my SCR to include Additional Information (Recommended)

I do not want my SCR to include Additional Information

Children under 16 years will be registered with “Additional Information” for Child Health Information Services purposes

Your choice for OCS *

I would like my information shared through the Oxfordshire Care Summary

I do not want my information shared through the Oxfordshire Care Summary

Medical History

Child under 16 years

Is the child registered disabled? *

Yes

Your child will be registered with the Child Health Information Service to monitor and improve uptake of national childhood screening and immunisation programmes.

A Summary Care Record with “Additional information” will be created to provide Child Health Information Service access to a summary of your child’s medical records to enable this.

For more information visit: www.scwcsu.nhs.uk

Child under 5 years

Please tick the box to confirm that you wish the child above to be registered with a doctor for Child Health. We recommend Yes to this.

Information for child health records

Immunisations - Please ensure the following immunisation history is completed fully with actual dates from the child's "Red Book" or medical record document.