Patient Details Title (optional)—Please choose an option—MrMrsMissMs Surname First name(s) Previous Surname/s (optional) Birth Town Birth Country Date of Birth NHS Number (optional) Postcode Sex (optional)MaleFemale Telephone Address Previous UK Registration Details I am a student at: (optional) Previous address in UK (optional) Name of previous GP practice while at that address (optional) Address of previous GP practice (optional) Your first UK address where registered with a GP (optional) If previously resident in UK, date of leaving (optional) Date you first came to live in UK (optional) UK Armed Forces / Ministry of Defence 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 (optional)RegularReservistVeteranFamily Member (Spouse, Civil Partner, Service Child) Enlistment Date (optional) Discharge date (if applicable) (optional) Service or Personnel Number (optional) Address before enlisting (optional) Dispensing of Medicines and Appliances If you need your doctor to dispense medicines and appliances (optional)I live more than 1.6km in a straight line from the nearest chemistI would have serious difficulty in getting them from a chemist Patient Signature Signature (optional)Signature of patientSignature on behalf of patient Signed (optional) Date (optional) Ethnicity What is your ethnic group?—Please choose an option—BritishIrishIrish TravellerTravellerGypsy/RomanyPolishOther WhiteWhite and Black CaribbeanWhite and Black AfricanWhite and AsianOther MixedIndianPakistaniBangladeshiOther Asian or Asian BritishCaribbeanAfricanSomaliNigerianOther Black or Black BritishChineseFilipinoOtherOther ethnic groupNot Stated Please enter details here (if Other) NHS Treatment Chargeable Status Please tick one of the following boxes: (optional)I understand that I may need to pay for NHS treatment outside of the GP practiceI 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 requestedI do not know my chargeable status Declaration 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. (optional)I confirm Parent / Guardian Details Are you a parent or guardian, filling out this form on behalf of a child under 16?YesNo Name parent or guardian (optional) Relationship to patient (optional) Signed (optional) Date (optional) EHIC / PRC Details Do you have a non-UK EHIC or PRC? (optional)YesNo Country Code (optional) Name (optional) Given Names (optional) Date of Birth (optional) Personal Identification Number (optional) Identification number of the institution (optional) Identification number of the card (optional) Expiry Date (optional) PRC validity period - From (optional) PRC validity period - To (optional) S1 Form Please tick if you have an S1 (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. (optional)I have an S1 form