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Important- Patient Note

Following the recent government guidance, the Southam Surgery team want to reassure our patients that we are still fully operational & working hard to ensure the best possible care for our local community. Read More. 

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Join The Practice

We welcome new patients who live within our practice area to register with us. Please check our practice boundary here.

The Practice catchment area covers Southam and the following villages: Bascote, Long Itchington, Stockton, Napton on the Hill and Ladbroke.

Anyone in England can register with a GP surgery. It's free to register. You do not need proof of address or immigration status, ID or an NHS number.

GP surgeries are usually the first contact if you have a health problem. They can treat many conditions and give health advice. They can also refer you to other NHS services. You do not need proof of ID to register with a GP, but it might help if you have one or more of the following:

Passport | Birth certificate | HC2 certificate | Rough sleepers' identity badge | Hostel or Accommodation registration |Mail forwarding letter

If you're homeless, you can give a temporary address, such as a friend's address, a day centre or the GP surgery address.

Please note: You will be asked to upload the ID proof in case you request online access to medical records.

Join The Practice Request

To register online please ensure that you complete all fields on both the new patient registration form and the health questionnaire that follows once you click ‘submit’.

Please ensure to fill in your Previous address on GP so we are able to trace your medical records.

Registrations will be processed within 14 working days

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Patient’s Details
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Health Questionnaire
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Online Access
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Patient’s Details

Title: *
Gender: *

Please provide a mobile telephone number wherever possible. By doing so, you will be automatically enrolled to our text reminder service. We will use this for: contacting you about your health when unable to contact you at home / texting your appointment reminders / responding to your queries / advising when your prescriptions/paperwork is ready / advising you if appointments are cancelled.

Parent/Guardian/Carer

Is your Parent/Guardian/Carer currently registered or in the process of registering, at the practice? *  

Please enter your Parent/Guardian/Carer details below:

Student

Previous Details

Find your NHS Number
Please include postcode.

Abroad

If you have only ever lived at one address please enter the same address here.

Armed Forces

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:  

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.

NHS Organ Donor Registration

Organ donation in England has moved to an 'opt out' system. This means that all adults in England will be considered to have agreed to be an organ donor when they die unless they have recorded a decision not to donate or are in one of the excluded groups.

You still have a choice about whether or not you wish to become a donor. If you wish to know more on the law and Opt Out from the register, please visit NHS Organ Donation.

NHS Blood Donor Registration

You can self-register on the NHS Blood Donor Register, if you wish to become a blood donor. Please visit the website to register.

Supplementary Questions

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 tick one of the following boxes

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.

Type your full name

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

EHIC OR PRC

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.

Next of Kin Details

Are any other family members registered with the Practice?  

Carers

It’s important that everyone who works here at Southam Surgery knows you are a carer so that we can offer you help and support if you need it. Anyone who looks after a friend or family member who cannot manage without them, and is unpaid, can register. This includes carers under the age of 18.

Please complete the Carer Information Form, to get your details added to your medical records.

Emergency Contact Details

Emergency Contact Details *  

Patient Participation Group

We have a patient participation group who meet with the practice on a quarterly basis. This group provides an effective way of patients and the surgery working together to improve services and to promote health and improved quality of care.

If you are interested in joining the group, please complete the Patient Participation Group Registration Form.

Ethnic Group

In compliance with the Race Relations (Amendment) Act 2000 and its Race Equality Scheme any new patient registrations are requested to complete this form.

Which of the following best describes your ethnic background? *  
Please Specify  
Please Specify  
Please Specify  
Please Specify  
Do you need an interpreter?  

Social Services

Are you or your children had any contact with social services?  
Please specify