Out of Area Registration Form

Sending this form will NOT automatically register you with the surgery. Your details will be held at the surgery for a limited period of time. You are required to be present in person to sign your registration form and provide proof of your address. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Please note – If your home address falls outside of our practice’s catchment area, you will not be eligible for home visit.

Part 1: Patient's Details

Your Name
(if applicable)
Date of Birth
(If known)
Home Address
(Please also provide flat number or room number where appropriate)
Email Address

Further Details

Are you a student?

Contacting You



We will from time to time have to contact patients via SMS text message. this is extremely helpful particularly in the current state of pandemic.

Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders?

Previous Medical Records

Please help us trace your previous medical records by providing the following information.
Have you registered with the NHS before?
Are you from abroad?
Are you returning from the Armed Forces?

Dispensing Of Medicines And Appliances

If you need a doctor to dispense medicines and appliances
(Not all doctors are authorised to dispense medicines)

Organ & Blood Donation

Would you like to register as an organ donor?
Are you/Would you like to register as a blood donor?

Patient Declaration

Are you ordinarily resident in the UK?
Patient Declaration
(A parent/guardian should complete the form on behalf of a child under 16)
Are you completing this form on behalf of a child under 16?

Non-uk European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC) Details

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
Do you have a non-UK EHIC or PRC?

S1 Form

Do you have an S1 form? If yes, please give your S1 form to the practice staff.
(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)

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.

Proof of Identity and Address Provided

We require proof of identity and address – please email a copy of your identity as well as proof of address to andover.medical-centre@nhs.net with “New registration ID” as the subject header. If you do not provide us with proof of ID and address we may be unable to proceed with your registration.
Proof of Identity

Complete Registration

Drop files here or
Max. file size: 1 GB, Max. files: 10.
    Proof of Address, Proof of Identity etc
    If you are registering a child under 5
    If you need your doctor to dispense medicines and appliances
    Signature
    (Full Name)