Order your medication – Kirby Road Surgery

Please use this form to order your medication if you don’t have an account with SystmOne.

Patient's details

Title(Required)

Mrs

Miss

Other

Please add your title

Name(Required)

First names Surnames

Previous surnames

NHS Number

Get help to find your NHS number online

Date of birth(Required)

Day

Month

Year

Are you(Required)

Male

Female

Town of birth(Required)

Country of birth(Required)

Home address(Required)

Postcode(Required)

Telephone number(Required)

Please help us trace your previous medical records by providing the following information

Your previous address in UK

Name of previous GP practice while at that address

Address of previous GP practice

If you are from abroad

Your first UK address where registered with a GP

If previously resident in UK, date of leaving

Day

Month

Year

Date you first came to live in UK

Day

Month

Year

Were you ever registered with an Armed Forces GP

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.

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

Regular

Reservist

Veteran

Family Member (Spouse, Civil Partner, Service Child)

Address before enlisting

Postcode

Service or Personnel number

Enlistment date

Day

Month

Year

Discharge date (if applicable)

Day

Month

Year

If you need your doctor to dispense medicines and appliances*

*Not all doctors are authorised to dispense medicines

I need my doctor to dispense medicines and appliances(Required)

Yes

I live more than 1.6km in a straight line from the nearest chemist

Yes

I would have serious difficulty in getting them from a chemist

Yes

Ethnic group

Please select one answer that best describes your ethnic group or background from the options below(Required)

White - British

White - Irish

White - Irish Traveller

White - Traveller

White - Gypsy/Romany

White - Polish

White - Other

Mixed background - White and Black Caribbean

Mixed background - White and Black African

Mixed background - White and Asian

Other Mixed background

Asian or Asian British - Indian

Asian or Asian British - Pakistani

Asian or Asian British - Bangladeshi

Other Asian background

Black or Black British - Caribbean

Black or Black British - African

Black or Black British - Somali

Black or Black British - Nigerian

Other Black background

Other ethnic group - Chinese

Other ethnic group - Filipino

Other ethnic group

Not stated (Not Stated should be used where the PERSON has been given the opportunity to state their ETHNIC CATEGORY but chose not to)

Please state your ethnic group or background

Supplementary questions

These questions and the patient declaration are optional and your answers will not affect your entitlement to register or receive services from your GP.

Are you ordinarily resident in the UK(Required)

Yes

PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

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 select one of the following options(Required)

I understand that I may need to pay for NHS treatment outside of the GP practice

I 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 requested

I do not know my chargeable status

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.

I agree to the statement above

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

You only need to 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.

I live in another EEA country, or I have moved to the UK to study or retire, or I live in the UK but work in another EEA member state.

Yes

Do you have a non-UK EHIC or PRC?(Required)

Yes

If yes, please enter details from your EHIC or PRC below:

3: Name(Required)

Country Code(Required)

4: Given Names(Required)

5: Date of Birth(Required)

Day

Month

Year

6: Personal Identification Number(Required)

7: Identification number of the institution(Required)

8: Identification number of the card(Required)

9: Expiry Date

Day

Month

Year

PRC validity period (a) From:

Day

Month

Year

PRC validity period (b) To:

Day

Month

Year

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. 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.

Yes I have an S1 form

Privacy consent

Not for urgent medical help(Required)

Yes, I understand this form is NOT for urgent medical help

Consent(Required)

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.

I agree to the privacy policy.

Comments

This field is for validation purposes and should be left unchanged.