Join the practice

New Patients

We are always happy to accept new patients and can register people who live within Ipswich postcodes of IP1 to IP4 inclusive. We are also able to register patients who live outside IP1 to IP4, however as this is outside our boundary area, we will not be able to provide a home visiting service as part of your registration with us.

Patient Leaflet

Registration with the practice

If you wish to register please complete the form below.

Please Note: Due to the COVID-19 pandemic, we ask that ALL registrations are done electronically. Please do not bring paperwork to the Surgery - we are currently not allowing patients without a pre-triaged appointment into the building. We have also temporarily suspended the need for us to check identification when registering.

Additionally, we have noticed that some patients may be unable to register using the form below if you are using Internet Explorer. Please try another internet browser such as Google Chrome, Microsoft Edge or Apple Safari instead.

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Patient's Details

Information we need to register you with the practice
Please note all fields marked with a * are mandatory for your registration

Title: *

Gender: *

Are you happy for us to contact you by email?:

Are you happy for us to contact you by letter? :

Are you happy for us to contact you by text message? :

Do you have a nominated pharmacy for electronic prescribing?:

Ethnicity & Religion

Please specify the ethnic group you consider you belong to: *

Your Religion:

Do you speak English?:

Do you read English?:

Allergies

Do you have any allergies?: *

Previous Details

Please include postcode

Are you registering for the first time in the UK? : *

Are you returning from abroad?:

If you are from abroad

Please use this date format: DD/MM/YYYY

Refugee: *

Asylum Seeker: *

Do you require an interpreter when you see the doctor/nurse?: *

If you are returning from abroad

Previously been registered with the NHS in the UK

Please use this date format: DD/MM/YYYY

Were you ever registered with an armed forces GP?

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:

Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services

Supplementary Questions

Please select one of the following statements::

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 at reception. Alternatively for more information go to www.nhs.uk/nhs-services/visiting-or-moving-to-england

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.

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.

Please enter the details from your EHIC or PRC below.

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.

Carers

Do you have a carer?: *

Are you a carer for someone?: *

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

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Lifestyle

Smoking Status:

Are you interested in advice on how to quit?:

Your Personal Alcohol Consumption

alcohol consumption Image 1 unit

How often did you have a drink containing alcohol in the past year?:

How many drinks containing alcohol did you have on a typical day when you were drinking in the past year?:

How often did you have six or more drinks on one occasion in the past year?:

Audit Score Result

you have a score of

If you are drinking less than 14 units of alcohol per week, then your drinking is within the UK Chief Medical Officers' low risk drinking guidelines.

But if you are drinking regularly at or above the low risk guidelines of 14 units a week, or, you are drinking six or more units - if you are female - or eight or more units - if you are male - in one single session (binge drinking), please consider the increased serious risks to your health being caused by your current drinking pattern.

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Adult Females

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

Was it done at:

Have you had a hysterectomy?:

Do you still have your ovaries?:

Do you still have your cervix?:

Immunisation History

Please include dates.

Medical History

Please include dates.

How do you describe your sight?:

How do you describe your hearing?:

Over 75 years old?

The Department of Health has advised that all patients of 75years and older have a named and accountable GP to oversee their care. Please ask the name of the GP assigned to oversee your care. Please note this does not prevent you from seeing the GP of your choice.

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Identification Upload

Patient Identification

To fully register you at the practice, we need Two forms of Acceptable ID (if not possible, please let us know).

We will not store these documents and we will securely delete / destroy them after our initial verification.

OPTIONAL: Photo of your face to add to your records to help us identify you (if you agree)

Acceptable Identification: Photo Driving License, Passport, Tenancy agreement, Mortgage statement, Bank statement, Utility bill (date within the past 3 months) etc.

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NHS Organ Donor registration

For more information on organ donation please visit: www.organdonation.nhs.uk

NHS Blood Donor registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323

What happens to my information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Overseas Visitors

Overseas visitors are some times entitled to free treatment and some times have to pay.

It is up to the GP or Dentist whether to accept you onto their list of NHS patients. They may accept you on their list if you are living in the UK, but they don't have to.

Visitors are not usually entitled to get non-hospital treatment. For example, if you used to live in the UK and then went to live abroad, you wouldn't normally get free treatment if you came back for a visit. There are some exceptions to these rules, for example, if you need emergency treatment, contraception or attending Walk in Centres.

A GP may, in practice, be flexible in deciding whether you are resident in the UK, in order to qualify for free treatment. You will usually have to show that your stay in the UK has some degree of permanence and stability.

If you are a visitor in the UK for less than three months, a GP may accept you as a temporary resident. Otherwise, a GP may offer to accept you as a private patient and you will have to pay for treatment.

You may have difficulty finding a GP or a Dentist who is prepared to register you. In this situation you should contact your Clinical Commissioning Group or Local Health Board. In England and Wales, you can also get help to find a Doctor from NHS 111 on 111. In Scotland, you can contact NHS 24 on 0845 424 2424. In Northern Ireland, you should contact the Central Services Agency on 028 9032 4431.

Even if you are accepted onto a GP or Dentist's list of NHS patients, you have to pay charges for some things like prescription charges and dental treatment.

For more information about charges and the help you might get to pay for them, see Help with health costs.

Summary Care Record

Your Summary Care Record will contain important information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines that you have had.

Giving healthcare staff access to this information can prevent mistakes being made when caring for you in an emergency or when your GP practice is closed.

Your Summary Care Record will also include your name, address, date of birth and your unique NHS Number to help identify you correctly.

You may want to add other details about your care to your Summary Care Record. This will only happen if you ask for the information to be included. You should discuss your wishes with the healthcare staff treating you.

Click here to view a leaflet containing more information.

You can choose not to have a Summary Care Record. You need to let your GP practice know by filling in and returning an opt-out form.

Click here to download an opt-out form.

Non English Speakers

These fact sheets have been written to explain the role of UK health services, the National Health Service (NHS), to newly-arrived individuals seeking asylum. They cover issues such as the role of GPs, their function as gatekeepers to the health services, how to register and how to access emergency services.

Special care has been taken to ensure that information is given in clear language, and the content and style has been tested with user groups.

Open the leaflets in one of the following languages:

English	Urdu
Albanian	Hindi
Arabic	Lithuanian
Bulgarian	Polish
Chinese (Cantonese)	Portuguese
Chinese (Mandarin)	Spanish
Russian	French
Turkish	Punjabi
Gujerati	Somali
Croatian	Bengali
Farsi