Online Secondary or Visitor Registration Form For adult and child. Please complete clearly all relevant sections of this registration form. When completing this form make sure you have with you your photo ID, proof of address and, for Jersey residents, your green health card . You will be asked to upload these documents before submitting this registration.1. Patient InformationYour Name Title Mr.Mrs.MissMs.Dr.Prof.Rev. Given Name Family Name Known as OptionalDate of birth MM slash DD slash YYYY Resident in Jersey since MM slash DD slash YYYY Jersey Social Security Number OptionalNot required for visitorsDo you hold a Green Health Card?YesNoPatients need a health card to get a subsidy when visiting General Practitioners (GPs). Health cards are issued if a resident has lived in Jersey for at least 6 months and have paid Social Security contributions. For the first 6 months after arriving in Jersey, new residents don’t hold a health card and will have to pay the full cost should they need to visit a GP or another health care provider. Gender IdentityMaleFemaleNon-binaryAgenderTransOtherEthnicity (a)WhiteBlackAsianMixedOtherEthnicity (b)BritishEuropeanOtherFirst Language (if not English) OptionalReason for registering with the Practice Visitor On business Non-resident contractor Secondary/Specialist Service Second Opinion NOTE: Patients that are not Jersey residents are charged the full service cost should they need to visit a GP or another health care provider2. Home Address and Contact InformationCurrent home address House Name / Flat Name Number & Street Parish / Town Postcode Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Mobile Tel No.Home Tel No. OptionalWork Tel No. OptionalConsent to receive SMSYesNoPersonal Email Address Email Address Confirm Email Address Consent to receive emailsYesNo3. Visitor InformationIf you are a Jersey Resident you can just write N/AJersey home address House Name / Flat Name Number & Street Parish / Town Postcode Date of arrival Optional MM slash DD slash YYYY Date of departure Optional MM slash DD slash YYYY 4. Emergency Contact/Next of Kin InformationName Title Mr.Mrs.MissMs.Dr.Prof.Rev. Given Name Family Name Date of birth Optional MM slash DD slash YYYY Mobile Tel No.Personal Email Address Optional Home address House Name / Flat Name Optional Number & Street Optional Parish / Town Optional Postcode Optional Country Optional AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Relationship to the patient:Is this your Nex Of Kin?YesNoDo you give consent to discuss your record?YesNoIs this your official carer?YesNo5. Private Medical InsuranceThe Patient is responsible for making all claims with the insurer. Payment for services must be done by the patient and ask insurer for reimburse Insurance Provider Optional6. Medical HistoryAllergies: Do you (or the child) have any known allergies or do they have any adverse reaction to drugs or medicationYesNoIf YES, please provide details: OptionalMedication: Does you (or the child) currently take any medication?YesNoIf YES, please provide details: OptionalDo you (or the child) suffer from any significant ongoing medical problems or had any serious illness/operations in the pastYesNoIf YES, please provide details: Optional7. Existing GP InformationGP NameName of GP PracticeTel No.8. Patient Declaration, Confidentiality Agreement, Personal Data Statement and CommunicationIn the case of a child under the age of 16, This declaration should be signed ‘for and on behalf of’ the child named on this registration form by the Parent/Legal Guardian as given in section 4.Personal Information (Data Protection and Patient Privacy): I understand that the information collected on this application form will be used by First Medical Ltd (hereafter the ‘Practice’) for the purposes of healthcare related services and practice administration. I understand that personal information First Medical hold about me is processed for the purposes of ‘Employment and Social Fields’ (Article 8) ‘Medical Purposes’ (Article 15) and ‘Public Health’ (Article 16) of the Data Protection (Jersey) Law 2018. I understand that this may require your personal data including, relevant details of your medical history, to be shared with other approved healthcare providers for the purpose of referrals and for other lawful purposes related to the Practice procedures. Select AllFurther information on how we hold and process your data can be found in our Data Protection and Patient Privacy Policy.General Practice Central Services (GPCS): I understand that all Jersey GP Practices and other approved healthcare service providers, such as the out-of-hours doctors, use a central medical records system known as EMIS. I understand this allows access to a ‘shared medical record’ to ensure that the provider or clinician has immediate up-to-date and accurate information about your health and any current treatment you may be having. I understand that I have the right to ‘opt out’ of sharing some or all of my medical records. I can ask the practice for more information and if appropriate an Opt-in/Out Form for completion. Select All All approved healthcare service providers with authorised access to GPCS have signed strict confidentiality agreements which are bound by the Data Protection (Jersey) Law 2018. Children Aged 13-16 I understand that The Data Protection (Jersey) Law 2018 provides that a child aged between 13 and 16 has their own right to consent and data confidentiality privacy I understand a child aged between 13 and 16 has “sufficient understanding and intelligence to enable them to understand fully what is proposed” (known as Gillick Competence), then they may be competent to give consent for themselves I understand Further information can be found in the practice Data Protection and Patient Privacy Policy Select All Your Declaration to us: • I confirm that all the information I have given in this registration form is accurate to the best of my knowledge. • I understand that the Practice has the right to accept or decline my registration application at any time. • I understand that by attending a consultation with a GP or other healthcare professional of the Practice, I accept the Practice terms of service and fee schedule issued and displayed in the Practice premises and as amended from time to time. • I hereby agree to pay any incurred service fees from the Practice at the time of attendance or treatment. • I expressly consent that on registration or prior to accepting any credit arrangement from the Practice, where appropriate a credit reference check may be taken with an authorised credit reference agency and/or my previous medical practice(s). • I give my express permission for the Practice to request information including my medical records from my previously registered GP and I agree to reimburse the Practice for any charges and disbursements incurred relating thereto for the Practice being provided with such information. • I understand it is my sole responsibility to advise the Practice in writing of any changes made in respect of my personal information. Select AllSignaturePrint Name(Parent/Legal Guardian if for child named below)Child's NameOnly for child registration. If not the case, please write N/ARegistration Request Date MM slash DD slash YYYY Photo IDMax. file size: 1 GB.Valid passport, driving license or identity cardProof of addressMax. file size: 1 GB.Utility bill dated within 3 months; this document must have your nameGreen Health Card (For Jersey Residents) OptionalMax. file size: 1 GB.if you don’t hold a green card, please upload copy of your Social Security Card. However, without a green health card you will be charged full price until the card is presentedEmail OptionalThis field is for validation purposes and should be left unchanged.
