Access To Temporary Services GMS3(W)

Although our Online Services are monitored regularly, this is not an urgent form of communication. If requesting access as a temporary resident, you will be required to call our Reception Team alongside the completion of this form. This allows us to gather the required information to arrange appropriate treatment, and to ensure we are aware that a form is being completed. We will email/text you with confirmation that your form has been received, processed and will provide details of appointment that has been arranged.

Last Updated: 10/08/2022

Patient Details

Title

Mrs

Miss

Email Address *

Surname *

First Name(s) *

Date of Birth *

Previous Surnames

NHS Number (This comprises of 10 numbers)

Temporary Address

Address *

Postcode *

Telephone Number *

Home Address

Address *

Postcode *

Telephone Number *

Details of treatment should be sent to

Registered GP Surgery Name and Address *

Declaration

SMS Consent *

SMS TEXT MESSAGING IS A SERVICE OFFERED ACROSS WALES WHERE ALL GP PRACTICES HAVE THE ABILITY TO SEND TEXT REMINDERS FOR SMS TEXT MESSAGING AND INFORMATION ABOUT SERVICES TO PATIENTS. IF OFFERED BY MY PRACTICE, I AM HAPPY TO BE CONTACTED VIA SMS TEXT MESSAGING

I DECLINE THE SMS TEXT MESSAGING SERVICE

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

I consent to the practice collecting and storing my data from this form.

I declare to the best of my belief this information is correct

Authorised Signature

Name

Date

Practice Stamp

Clinical Information

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Access To Temporary Services GMS3(W)

Further Information