CEP PATIENT REGISTRATION

In order to better manage and inform you regarding your health needs, it is essential that we have up to date information, including contact details.  Please complete this registration form as soon as possible.

In order to provide information to clinicians to make sure the care provided to you is safe and effective, DPHC keep records about your health and any treatment and care you receive from DPHC. The Defence Primary Healthcare patient privacy notice  lets you know what happens to any personal data that you give to us, or any that we may collect from or about you and explains how we collect and process this to meet our obligations to you. The personal data we collect about you may also be provided to other approved organisations, where there is a legal basis, to help with improving the care provided, research into new treatments and preventing illness. These help to provide better health and care for you, your family and future generations. Personal data about your health and care is only used in this way where allowed by law and would never be used for insurance or marketing purposes without your explicit consent. You have a choice about whether you want your personal data to be used in this way, visit www.nhs.uk/your-nhs-data-matters . If you do choose to opt out, you can still consent to your personal data being used for specific purposes.

A form must be completed for both the Service person and dependants.

Registration Form

I am/the serving person in this family is *ArmyRAFNavyUKBC

Service/Staff Number *

Rank/Title *

First Name *

Last Name *

Date of Birth *

Sex at birth *

Gender *

Contact telephone number *

Please use a telephone number you will be using while in location.

Civilian email address *

Further work email addresses can be added at a later date but for registration purposes please ensure this is a civilian email address

Country of Assignment *

Town of Assignment *

Expected/Actual Date in Country *

Are you a Carer? *

• Yes
• No

Are you a Care Leaver? *

• Yes
• No

Are you pregnant or under the care of a midwife? *

• Yes
• No
• N/A

Do you hold a firearms licence? *

• Yes
• No

Previous UK Postal Address *

Required for Civil Servants and spouses/family members to allow us to request and track UK GP records. For serving personnel, please type N/A

I have additional family members to add (1) *

• Yes
• No

I amSpouse/PartnerChild who will be accompanying to postChil who will be in Boarding School/University

First Name

Last Name

Date of Birth

Sex at birth

Gender

Contact Telephone Number

Civilian email address

Further work email addresses can be added at a later date but for registration purposes please ensure this is a civilian email address

Expected/Actual arrival date in country

Are you a carer?

• Yes
• No

Are you a care Leaver?

• Yes
• No

Are you pregnant or under the care of a midwife?

• Yes
• No
• N/A

Previous UK Postal Address

Required for Civil Servants and spouses/family members to allow us to request and track UK GP records.

I have additional family members to add (2) *

• Yes
• No

I amSpouse/PartnerChild who will be accompanying to postChil who will be in Boarding School/University

First Name

Last Name

Date of Birth

Sex at birth

Gender

Contact Telephone Number

Civilian email address

Further work email addresses can be added at a later date but for registration purposes please ensure this is a civilian email address

Expected/Actual arrival date in country

Are you a carer?

• Yes
• No

Are you a care Leaver?

• Yes
• No

Are you pregnant or under the care of a midwife?

• Yes
• No
• N/A

Previous UK Postal Address

Required for Civil Servants and spouses/family members to allow us to request and track UK GP records.

I have additional family members to add (3) *

• Yes
• No

I amSpouse/PartnerChild who will be accompanying to postChil who will be in Boarding School/University

First Name

Last Name

Date of Birth

Sex at birth

Gender

Contact Telephone Number

Civilian email address

Further work email addresses can be added at a later date but for registration purposes please ensure this is a civilian email address

Expected/Actual arrival date in country

Are you a carer?

• Yes
• No

Are you a care Leaver?

• Yes
• No

Are you pregnant or under the care of a midwife?

• Yes
• No
• N/A

Previous UK Postal Address

Required for Civil Servants and spouses/family members to allow us to request and track UK GP records.

I have additional family members to add (4) *

• Yes
• No

I amSpouse/PartnerChild who will be accompanying to postChil who will be in Boarding School/University

First Name

Last Name

Date of Birth

Sex at birth

Gender

Contact Telephone Number

Civilian email address

Further work email addresses can be added at a later date but for registration purposes please ensure this is a civilian email address

Expected/Actual arrival date in country

Are you a carer?

• Yes
• No

Are you a care Leaver?

• Yes
• No

Are you pregnant or under the care of a midwife?

• Yes
• No
• N/A

Previous UK Postal Address

Required for Civil Servants and spouses/family members to allow us to request and track UK GP records.

I have additional family members to add (5) *

• Yes
• No

I amSpouse/PartnerChild who will be accompanying to postChil who will be in Boarding School/University

First Name

Last Name

Date of Birth

Sex at birth

Gender

Contact Telephone Number

Civilian email address

Further work email addresses can be added at a later date but for registration purposes please ensure this is a civilian email address

Expected/Actual arrival date in country

Are you a carer?

• Yes
• No

Are you a care Leaver?

• Yes
• No

Are you pregnant or under the care of a midwife?

• Yes
• No
• N/A

Previous UK Postal Address

Required for Civil Servants and spouses/family members to allow us to request and track UK GP records.

I am aware that the CEP may contact myself or my family members for further information if required.

• Yes

I herby confirm the requirement for myself and my family members to enrol with the MOD Healthcare Partner One HMG (Healix) and understand that we should seek clinical care initially through the local host nation system. For further information please refer to the CEP Practice Information Leaflets.

• Yes

GDPR Consent

• I consent to having the Central European Practice store my submitted information to enable them to perform medical support functions required by Defence.

Submit

De-Registration Form

Service/Staff Number of Serving Person De-Registering *

First Name *

Last Name *

Date of Birth *

Expected leaving date *

Expected new unit (Service Personnel Only) *

I have family members to de-register (1) *

• Yes
• No

Name *

First

Last

Date of Birth *

I have family members to de-register (2) *

• Yes
• No

Name *

First

Last

Date of Birth: *

I have family members to de-register (3) *

• Yes
• No

Name *

First

Last

Date of Birth *

I have family members to de-register (4) *

• Yes
• No

Name *

First

Last

Date of Birth *

I have family members to de-register (5) *

• Yes
• No

Name *

First

Last

Date of Birth *

Expected New GP Facility (Civilians Only) - If unknown please indicate this in the box *

GP Postal Address - If unknown please indicate this in the box *

I herby confirm the de-registration of myself and my family members. I am aware that the CEP may contact myself or my family members for further information if required. *

• Yes

GDPR Consent *

• I consent to having the Central European Practice store my submitted information to enable them to perform medical support functions required by Defence.

Submit

How to get your NHS Number