Family doctor services registration GMS1 GSM1 Patient s details Please complete in BLOCK CAPITALS and tick as appropriate Mr Mrs Miss Ms Date of Birth NHS No. Surname Male Female Town and country of birth Home address Postcode... First names... Previous surname/s... Telephone number Please help us trace your previous medical records by providing the following information Your previous address in UK...... Name of previous doctor at that address...... If you are from abroad Your first UK address where registered with a GP If previously resident in UK, date of leaving If you are returning from the Armed Forces Address of previous doctor Date you first came to live in UK Address before enlisting Service or Personnel number If you are registering a child under 5 Enlistment date I wish the child above to be registered with the doctor named overleaf for Child Health Surveillence If you need your doctor to dispense medicines and appliances* I live more than 1 mile in a straight line from the nearest chemist I would have serious difficulty in getting them from a chemist * Not all doctors are authorised to dispense medicines NHS Organ Donation registration I would like to join the NHS Organ Donation Register as someone whose organs may be used for transplantation after my death. Please tick as appropriate. Kidneys Heart Liver Corneas Lungs Pancreas Any part of my body Signature confirming consent to organ donation... For more information, please ask for the leaflet on joining the NHS Organ Donor Register NHS Blood Donor registration I would like to join the NHS Blood Donor Register as someone who may be contacted and who would be prepared to give blood. Tick here if you have given blood in the last 3 years Date Signature confirming consent to inclusion on the NHS Blood Donor Register... For more information, please ask for the leaflet on joining the NHS Blood Donor Register. My preferred address for donation is: (only if different from above e.g. Your place of work)... Postcode:... To be completed by your doctor Doctors Name HA Code I have accepted this patient for general medical services For the provision of contraceptive services I have accepted this patient for general medical services on behalf of the doctor named below who is a member of this practice Doctors Name, if different from above Date HA Code I am on the HA CHS list and will provide Child Health Surveillance to this patient or I have accepted this patient on behalf of the doctor named below, who is a member of this practice and is on the HA CHS list and will provide Child Health Surveillance to this patient. Doctors Name, if different from above HA Code I will dispense medicines/appliances to this patient subject to Health Authority s I am claiming rural practice payment for this patient. Distance in miles between my patient s home address and my main surgery is I declare to the best of my belief this information is correct and I claim the appropriate payment as set out in the Statement of Fees and Allowances. An Audit trail is available at the practice for inspection by the HA s authorised officers and auditors appointed by the Audit Commission. Authorise Signature Practice Stamp Signature of Patient Signature on behalf of patient Date Name Date Version 01/02 Please see right re: Organ donation HA use only Patient registered for GMS CHS Dispensing Rural Practice
GUIDELINES FOR FILLING OUT A FAMILY DOCTOR SERVICES REGISTRATION (GMS1) FORM PLEASE NOTE! For all registering adults (aged 16 or over) we ask you provide the following upon registration: We ask for proof of ID when you register, please bring one with you when you return the form. (Driving licence, passport, or other photo ID or document proving your identity. We ask for this information to combat NHS fraud and to try to reduce duplication of patients on NHS systems. If you have NEVER registered in the UK before under the NHS we also ask for proof of address e.g. a recent utility bill or other proof of address. Please complete the forms using CAPITAL LETTERS and as appropriate. PATIENTS DETAILS Mr. Mrs. Miss Ms Tick the appropriate box according to your marital status. Surname Surname or Family name. Please make sure the spelling given, is the same that appears on your passport, driving licence or home office paper work. Date Of Birth - The date you were born. Please enter the Day then the Month and finally the Year within the boxes given. First Names - First name or Forename. Please make sure the spelling given, is the same that appears on your passport, driving licence or home office paper work. Previous Surname/s - If you are married please state your maiden name or if you have changed your Surname/Family name at any time please state your last previous Surname/Family name. NHS Number - If you know your NHS Number which can be found on a medical card, please write it down in the boxes provided. You will not have one if you have not been registered with a doctor in the UK before. This is not your National Insurance Number. Your NHS number greatly speeds up retrieval of your records. Male / Female - Please tick the appropriate box. Town and Country of Birth - Please enter the Town and County of Birth if you were born in this country, for example, Bristol, UK. If you were born abroad please state the Country and Town if possible, for example, Bombay-India, Madrid-Spain or Naples-Italy. Home Address - Please print clearly your full postal address. If you are living in a house that is made up of Flats please state clearly the Flat name and the Road, Street, Avenue or Close name. Post Code - You need to print clearly a full post code; your address is incomplete without a postcode. An example of a postcode is TF9 3AL.
If your address details are not filled in clearly and correctly this could create a delay in receiving your Medical Records from your previous UK doctor if you have one or, even being taken off the Practice List if we cannot contact you. Telephone Number - Please enter as many forms of contacting yourself by phone, so write down Home, Mobile or Work phone numbers if available.. Please help us trace your previous medical records by providing the following information Your Previous Address in UK - If you were previously registered with a GP Practice in the UK then please write the address you were living at when registered. If you have left the country and are now returning again please write the address when you were last registered with a GP Practice within the UK. If you have never, to your knowledge, been registered with a GP Practice then just state your previous address where you were living. Name of previous Doctor while at that address - Please state the Doctors name within the GP Practice where you were registered if you know it. Address of previous Doctor - Please state the Address of the GP Practice, for example, Town Square Medical Practice, Easton, Bristol. If just arriving into the country and you are unsure if you have been registered with a GP Practice, still state the area where you may have visited a GP Practice. IF YOU ARE FROM ABROAD Your first UK address where registered with a GP - If this is your first visit to the UK please state the address you first stayed at. If you are returning back to the UK please state the address where you were last registered with a GP Practice within the UK. If previously resident in UK, Date of leaving - If you have visited the UK previously and you are now returning back to the UK, please state the date you left the UK. Date you first came to live in UK - If you have arrived in the UK for the first time please state the Date you arrived. If you are returning back to the UK, please state the date you arrived but remember to also fill in the date you left. IF YOU ARE RETURNING FROM THE ARMED FORCES This should only be completed if you are returning from serving as a member of the UK Armed Forces otherwise please ignore this section Address before enlisting - Please state the address where you were last registered with a GP practice before enlisting. Service or Personnel number - This can be found on your Discharge Papers. Enlistment Date - This can be found on your Discharge Papers.
You can ignore the sections If you are registering a child under 5 as this is no longer applicable. Please also ignore the section If you need your doctor to dispense medicines and appliances*. The surgery staff will tell you where you can have any prescription that you are given dispensed. Signature of Patient - Please sign the form beneath and tick the box to say if you are the patient or if you are representing the patient please tick the box Signature on behalf of patient (Signature on behalf of patient) Date - Please enter the date on which you are signing the form. The reverse of the form is divided into two sections, one is to register to donate your organs for transplantation after your death and to register to donate blood and the bottom of the form is for completion by the doctor. You do not need to complete either section. If you wish to register to donate your organs for transplantation after your death or to register to donate blood please visit the website www.uktransplant.org.uk or www.blood.co.uk It is very important that this form is filled in accurately or this may mean a delay in receiving your medical records. ETHNICITY FORM We also ask that you complete an ethnicity and spoken language form. These details are important. Your ethnic background can affect certain medical conditions and also certain blood tests can be inaccurate without taking into account ethnicity. NEW PATIENT CHECK We ask all registering patients over the age of 5 to have a new patient health check. This is an appointment with one of our health care assistants or nurses where a brief health survey is completed and some basic tests (BP, height, weigh, urine dipstick). Please call to book the appointment after you have registered. You will need to bring a sample of urine with you for the appointment for the nurse to check. Bottle can be obtained from our Main Reception. YOU SHOULD NOW ASK THE SURGERY STAFF TO CHECK THEY HAVE ALL THE INFORMATION THEY NEED ON THE GMS1 FORM BEFORE LEAVING THE SURGERY.
To Be Completed by Patient Form B If you consent to the texting of appointment reminders, when this facility becomes available, please tick here: Mobile Phone Number: (please remember to let us know if this changes!) Next of Kin If you want to provide details of a next of kin, please give them below. This information is stored on your record, if it changes, please let us know. Name of Next of Kin: Date of Birth: Contact Number: Ethnicity & Language Please note that ethnic origin is not about nationality, place of birth or citizenship. We ask this question as some blood tests and aspects of medical care can be affected by your ethnic background. I would describe my ethnic origin as (indicate one only): White British Mixed White & Black African Asian or Asian British Pakistani Black or Black British African White Irish White & Asian Asian or Asian British Bangladeshi Any other Black Please indicate your first language below: English or other (specify): Any Other White Any Other Mixed Any other Asian Other Ethnic Group Chinese Mixed White & Black Caribbean Asian or Asian British Indian Black or Black British Caribbean Other Ethnic Group Specify: Accessible Information Standard Will you require an interpreter when speaking to a Doctor or Nurse? Yes No Do you have any communication difficulties that we should be aware of? E.g. hearing difficulty or visual impairment. Please provide details: If you currently drink, please complete the questionnaire below: Audit-C Questions Scoring System Your Score How often do you have a drink containing alcohol? How many units of alcohol do you drink on a typical day when you are drinking? How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? 0 1 2 3 4 Never Monthly or less 2-4 times per month 2-3 times per week 4+ times per month 1-2 3-4 5-6 7-9 10+ Never Less than monthly Monthly Weekly Daily or almost daily Total Alcoholic Drink Units Alcoholic Drink Units Alcoholic Drink Units ½ pint of normal beer (4%) 1 1 25ml shot of spirits 1 1 small (125ml) glass of wine 1 ½ 75ml ottle of al opops 1 ½ ½ pint of strong beer (6.5%) 2 1 normal (175ml) glass of wine 2 1 pint/bottle of normal beer (4%) 2 1 large glass (250ml) of wine 3 1 pint/ bottle of strong beer (6.5%) 3 1 bottle of wine (750ml) (12.5%) 9 1 bottle of spirits (750ml) 40% 30
OFFICE USE ONLY *Must be completed by a Receptionist* Registration Form Please complete the following checklist before the patient leaves, if anything cannot be ticked please give back to the patient to complete before accepting their form. Name New Address Confirmed address is in our area, we do not accept registrations out of area Date of Birth Previous GP Details Previous Address Place of Birth Dates of enlistment/ discharge or arrival in the UK Not relevant Proof of ID Seen (please tick at least one form of ID seen) Not relevant (patient is under 16 and parent/guardian has completed form) Passport Driving Licence Utility Bill Financial Statement Other (please specify): Proof of Address Not relevant (patient is not new to the NHS) Utility Bill Financial Statement Other (please specify): Tell/remind patient: Patient informed of their named GP? Fully completed Form B Give them the Accessible Information Form if they have indicated communication difficulty. Read the SCR form Read the Online services form Remind them to bring ID when collecting their registration letter! Make a new patient health check Ask if they need a carer form and/or access to information form Checked & accepted by: Date: Computer entry by: Date: