Out of Area Registration Application

Since 2015 we have been able to register patients who live outside the pratice area but without any obligation to provide home visits.

We will only register a patient for an “out of area registration” without home visits if we decide that it is clinically appropriate and practical.

In order to decide this we will ask you to complete an application form.

We may then:

• Ask you questions about why it is practical for you to attend this practice
• If you are not currently registered at Paxton Green we may ask the practice you are currently registered with questions about your health to help decide whether to register you in this way

If accepted, you can attend the practice and receive the full range of services provided as normal at the surgery. If you have an urgent care need and you need help at home we may ask you to call NHS 111 and they will put you in touch with a local service (this may be a face to face appointment with a local healthcare professional or a home visit where necessary).

We may decide that it is not in your best interests or practical for you to be registered in this way. In these circumstances we will not register you and will advise you to register (or remain registered) with a more local practice.

If accepted but your health needs change we may review your registration to see if it would be more appropriate for you to be registered with a GP practice closer to your home.

New Patient Registration (out of area)

If you are human, leave this field blank.

In order to complete your registration, please ensure that you have your driving license and passport available.

Patient's Details

Title *

Mr

Mrs

Miss

Ms

Other

Please specify:

Surname: *

Previous Surnames:

First Name(s) *

Date of Birth: *

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

NHS Number:

Sex: *

Male

Female

Indeterminate

Home Address: *

Postcode: *

Town and Country of birth: *

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

Email Address: *

Can we contact you by text?

Yes

No

Can we contact you by email?

Yes

No

Reason for out of area application: *

Ethnicity

Please specify the ethnic group you consider you belong to:

White British

White Irish

Other White

Black Caribbean

Black African

Other Black

Black Caribbean and White

Black African and White

Other Mixed

Indian

Pakistani

Bangladeshi

Other Asian

I do not wish to state

Other ethnic group

Please state:

Do you speak English?

Yes

No

Do you read English?

Yes

No

First Language:

Emergency Contact

Full Name:

Relationship to you:

Phone Number:

Are they your Next of Kin?

Yes

No

Do you give us permission to discuss your medical records with them?

Yes

No

Electronic Prescription Service

The practice can send your prescription to your preferred pharmacy, please give us the name of this nominated pharmacy.

Pharmacy Name

Pharmacy Address:

Pharmacy Postcode:

Allergies

Do you have any allergies?

Yes

No

Please specify what you are allergic to, what happens and when you had your first reaction:

Previous Details

Previous address in UK:

Please include postcode.

Name and address of previous GP:

If you are from abroad

Registering for the first time in the UK

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.

Carers

Do you have a carer?

Yes

No

Are you a carer for someone?

Yes

No

Name of carer:

Phone Number:

Address:

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

Yes

No