You can opt out at any time, please contact us if you wish to do so. Please note: we will in your Vital interests send SMS texts that are required for your immediate health needs. Please see Our Privacy Statement for more information
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
Not all doctors are authorised to dispense medicines
Please indicate your ethnic origin. This is not compulsory, but may help with your healthcare, as some health problems are more common in specific communities, and knowing your origins may help with the early identification of some of these conditions.
Select the option that best describes your ethnic group or background from the options below
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.
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 tick one of the following boxes
Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.
If you have an S1 Form (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.
Please enter details from your EHIC or PRC below
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
The Electronic Prescription Service (EPS) allows prescriptions to be sent direct to pharmacies through IT systems used in GP surgeries. Eventually EPS will remove the need for most paper prescriptions. 99.3% of pharmacies use this system, with approximately 22 million patients using the service nationwide; over 934,226,838 items have been dispensed using EPS.
In order to set you up on EPS, we need you to choose a nominated pharmacy where we will send your prescriptions. Some controlled drugs cannot be sent via EPS, if you are unsure if your medication will be sent EPS please check when ordering your medication
Don’t worry; you can change your pharmacy in the future by simply contacting the surgery and asking to change your prescription destination.
The Summary Care Record (SCR) is an electronic record of important patient information, created from GP medical records. It can be seen and used by authorised staff in other areas of the health and care system involved in the patient's direct care. Access to SCR information means that care in other settings is safer, reducing the risk of prescribing errors. It also helps avoid delays to urgent care. If you are registered with a GP practice in England your SCR is created automatically, unless you have opted out.
As a minimum, the SCR holds important information about; current medication, allergies and details of any previous bad reactions to medicines, your name, address, date of birth and NHS number. We are encouraging patients to opt in to enhancing their SCR to provide other health care professionals with a better understanding of your history. Enhancing your SCR would include the following information;
• Significant medical history (past and present.)
• Reason for medication.
• Anticipatory care information (such as information about the management of long term conditions.)
• Communication preferences.
• End of life care information.
• Immunisations.
Occasionally you may want someone to be able to discuss your medical records with us. This could be a partner, relative or friend. Please consider this carefully, as if you provide consent for a named person, they will be able to discuss elements of your medical care with us. If you would like someone to be able to discuss your care with us, without us requiring additional consent, please provide their details below.
For children aged 13 and younger, we will only discuss their care with people deemed to have parental responsibility unless otherwise stated.
We reserve the right to refuse access to anyone other than the individual, the medical record pertains to if there are grounds that providing access is likely to cause serious physical or mental harm to the patient or the information you have asked for contains information that relates to a third person.
If yes please provide a copy of the legal documents.
There is an estimated 6.5 million people in the UK who provide care for a partner, relative or close friend, some are officially registered as carers and may receive carers allowance, while there are many that don’t. We gather information about carers so we can help to deliver the best possible service.
If yes please provide a copy of the legal documents
Please provide the dates you received the following immunisations (if you don't have the date just put 'not known')
If you would like help to stop smoking, please contact the local Quit Squad on 0800 328 6297.
Has any close relative suffered from the following
Any new patient currently prescribed Hypnotics (sleeping tablets) or Anxiolytics included in the list of medicines below, will be placed on a withdrawal regime at the time of registration unless a GP feels this is not appropriate
Are you currently prescribed or taking any of the following medications:
By registering with this practice, I agree to be started on a withdrawal regime unless a GP feels this is not appropriate.
Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.
All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
I consent to my information being used for the purposes described above and wish to submit this online form to Library House Surgery • Avondale Road, Chorley, Lancashire, PR7 2AD.
Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.
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