Patient’s details
    Please help us trace your previous medical records by providing the following information
    If you are from abroad
    Were you ever registered with an Armed Forces GP

    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.

    If you need your doctor to dispense medicines and appliances*

    *Not all doctors are authorised to dispense medicines

    NHS Organ Donor registration

    I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply.

    Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit or call 0300 123 23 23 to register your decision

    NHS Blood Donor registration

    I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

    My preferred address for donation is: (only if different from above, e.g. your place of work)

    All blood types are needed, especially O negative and B negative. Visit or call 0300 123 23 23.

    NHS England use only

    SUPPLEMENTARY QUESTIONS 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

    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 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.

    A parent/guardian should complete the form on behalf of a child under 16.

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

    PRC validity period

    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.

    Are you a carer? Carers Count is a 'one stop shop' for unpaid carers in Kirklees who give their time and energy to look after a family member or friend who needs support due to disability of illness. Carers Count can offer you:

    • A single point of contact
    • Useful information and advice including on benefits
    • Support with carers assessment
    • Group activities and training
    • Support to make sure you are heard
    • Involvement in how our service runs
    Carers Details

    If you would like us to be aware that you are a carer, please fill this in:

    Patient Participation Group

    This is a group of patients and GP practice staff who meet every 3 to 4 months and work together to improve the quality of care and outcomes for patients. PPGs become advocates for the practice and the services it provides. A thriving PPG is increasingly viewed as an indicator of a high-quality caring practice. If you are interested in becoming a member of our PPG please provide your details below:

    Electronic Prescriptions Service (EPS)

    At Rushden Medical Centre we are encouraging all our patients to sign up to the EPS service. This service helps reduce practice workload and enables a faster and more efficient prescription service. Benefits of EPS include:

    • Patients who opt into this service will no longer be required to pick up printed and signed NHS prescriptions.
    • Your electronic prescription will be sent securely to your nominated pharmacy.
    • You are able to change your nominated pharmacy at any time which may be useful if a prescription is to be collected near to a place of work or whilst on holiday.

    *Please note a limited number of medications cannot be sent to a pharmacy via EPS & therefore still require a printed prescription.

    Local Pharmacies

    Patients can choose a pharmacy that they wish to nominate as their preferred pharmacy for use with the Electronic Prescription Service.

    Electronic Prescriptions Nomination Form

    If you opt to use the Golcar Delivery Pharmacy service would you prefer to have medication delivered to:



    Do you currently suffer (or have ever suffered) from any of the following?

    Details of any impairment

    If yes please bring proof of medications into surgery


    Smoking Statust

    If would like your prescriptions to be delivered to your home or dispensed and dropped off at the surgery for you to collect at your convenience, please tick the box below and we will arrange this with our in-house pharmacy GDP. If needed you can contact GDP on 01484 646868.

    New guidance has been issued for the use of the Oxford AstraZeneca Covid-19 vaccine.

    This follows further reviews by the independent regulator, the MHRA, and the Commission for Human Medicines, of a very small number of people in the UK who have developed a rare blood-clotting condition since having the Oxford AstraZeneca Covid-19 vaccine.

    The MHRA and Joint Committee for Vaccinations and Immunisations have emphasised that the risk of this condition is extremely small and that the benefits of the vaccine outweigh the risks for the vast majority of people. They have recommended that:

    • Everyone who has had the AstraZeneca vaccine should still have a second dose of the AstraZeneca vaccine, irrespective of age, unless they suffered any serious side effects after their first vaccination.
    • People aged 30 and over or who have a health condition that puts them at higher risk of severe Covid-19 disease should still be offered the Oxford AstraZeneca vaccine.  The benefits in protecting them against the serious consequences of COVID-19 outweigh any risk of this rare condition.
    • People aged 18-29 who do not have a health condition that puts them at higher risk of severe Covid-19 disease will be offered an alternative Covid-19 vaccine where available.  (This has been recommended as a precaution as people under 30 are at less risk from Covid-19 and not because they are considered to be at particular risk of developing the rare blood clot.)
    • People under 30 can still choose to have the Oxford AstraZeneca vaccine if this will mean they can be protected more quickly and they have been made aware of the guidance.

     Please see the leaflet below that has been produced by Public Health England and the NHS to answer any questions you may have

     Leaflet on COVID-19 vaccination and blood clotting