New Patient Registration

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

To register a new patient you will need to live within our practice boundary.

Third Party Consent

You will need to complete a Consent to Third Party Access to Records form if you are 13 years of age and over and agree to someone else having access to your medical records, this will include: collection of documents, details of your appointments and discussing results.

We would also appreciate if you are collecting documents that you have consent to do so.

Temporary Patients

If you require medical attention and are temporarily within our practice boundary, under 3 months, please complete a Temporary Patients Registration form.

New Patient Registration - Fairlands

Patient's Details

Title *
Please use this date format: DD/MM/YYYY.
Sex *

Ethnicity

Please specify the ethnic group you consider you belong to: *
Do you speak English?
Do you read English?
Do you require an interpreter?

Home Address

Previous Details

Please include postcode.

If you are from abroad

Registering with the NHS for the first time in the UK
Are you from abroad and registering for the first time in the UK? *
Please use this date format: DD/MM/YYYY.

If you are returning from abroad

Previously been registered with the NHS in the UK
Please use this date format: DD/MM/YYYY.
Please use this date format: DD/MM/YYYY.

Patient Contact Details

Any responses we send will go to this email address.

Communication Needs

Can we contact you by text?
Can we contact you by email?

Next of Kin / Emergency Contact

Are they your next of kin?
Do you give us permission to discuss your medical records with them?

Nominate a Pharmacy

If you need a prescription, we will send it electronically. Please let us know the where you would like any existing or new prescriptions sent.

Summary Care Record

This practice has started the national Summary Care Record programme which enables each patient to have a summary of their key medical information held securely on the NHS central database, known as the NHS Spine. This summary record could be used in an emergency if you needed treatment when access to the medical record held by your GP was not available; for example if you call the doctor out of hours. You will always be asked to give permission for this record to be viewed and you have the right to decline.

Please indicate whether you would like to have your own Summary Care Record: *

How We Contact You

Any contact we make to you that is deemed "Direct Patient Care" will use one of the contact methods you have provided us with above.

However, to keep you updated we would like to occasionally send you additional information/updates about the Practice, this would include – Newsletters, patient surveys and information about the surgery.

Please select your preference below:

Patient Access

By registering for our online services, you will be able to:

  • Directly book/cancel/change appointments
  • Request a repeat medication
  • Change your nominated pharmacy
Would you like us to register you so you can download and use the app?

University Students

Are you currently a student at University of Surrey?

Were you ever registered with an Armed Forces GP

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:

Supplementary Questions

Ordinarily a Resident

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 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.

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

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.

EHIC/PRC

Please enter the details from your EHIC or PRC below.

S1 Form

Do you have an S1 Form?
Please give your S1 form to the practice staff.

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.