It is your responsibility to keep us updated with any changes to your telephone number, email & postal address. We may contact you with appointment details, test results or health campaigns
Select the option that best describes your ethnic group or background from the options below
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 select one of the following statements
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 of the GP practice, including at a hospital.
If yes, please enter details from your EHIC or PRC below
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.
If you are on repeat medications, you can now nominate a pharmacy for your prescriptions to be sent to electronically. This means that you do not need to come into the surgery to collect a paper prescription. We will send it electronically to the pharmacy of your choice. It could be a pharmacy near to where you live, work or shop.
The SCR record is a system that is linked up by the NHS Spine, it enables information to be shared between GP practices and emergency services such as Out of Hours, A&E and for in patients in hospital. This helps provide authorised clinicians involved in emergency care with faster secure access to key information about your health.
There are three options:
1. Express consent for medication, allergies & adverse reactions only
2. Express consent for medication, allergies, adverse reactions & additional information
3. Expressed Dissent (Opted Out)
Additional information could also be included, with your consent, this includes:
Significant medical history, past and present
Significant procedures, past and present
Anticipatory care i.e. DNR if in place
Palliative care information
Immunisations
If you would like to opt out from the summary care record, then please ask at reception for an opt out form
Children aged 10 or under - online access will be given to a parent/carer
Children aged 11-15 - online access can only be given to a parent/carer with the child’s consent
OR can be given to the child (with parental consent or at the discretion of a GP familiar with the child)
Parent/Carer access will be removed when a child is 16 years old. If a child over the age of 10 requests that we remove parent/carer access, this will be granted in cases where a GP who is familiar with the child agrees.
I would like the following:
* We do not currently offer access to other areas of the medical record of patients who are under 16 years of age. This decision may be reviewed when additional functionality for proxy access is available. Access to coded information on illnesses (Problem headings & coded data within Consultations) can be applied for by patients over the age of 16 who will be accessing their own data.
If child named in this form is aged 11-15 years old:
Your declaration
I confirm that:
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 City Way Medical Practice • 65-67 City Way, Rochester, Kent, ME1 2AY.
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.
Loading...