Out of Area Registration Out of Area Registration Are you completing this form for yourself? Yes No For who are you completing the form? Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Middle Last What is their date of birth? Day Month Year What is your name? Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Middle Last What is your date of birth? Day Month Year Phone OptionalAddress Street Address Optional Address Line 2 Optional City Optional County / State / Region Optional ZIP / Postal Code Optional AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman 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 Country Optional Has the patient required a home visit from the GP or out of hours in the last 12 months? Yes No Roughly how many visits have been required?How would you expect to usually travel to the surgery if required?Out of Area DeclarationDeclaration I understand and agree to the out of area declarationYou have requested registration at Marple Bridge Surgery and have an address outside of our practice boundary. We may still be able to register you providing we expect to be able to deliver the clinical care we aim to provide all our patients. Each application will be reviewed by our clinical and managerial teams. There may be clinical or practical reasons why this may not be possible and registration may be declined. Ensure you read through the information pack linked here: https://www.england.nhs.uk/publication/choice-of-gp-practice-guidance-on-the-new-out-of-area-patient-registration-arrangements/as this sets out the differences of an out of area registration. If accepted, you will attend the practice and receive the full range of services provided as normal at the surgery. If you have an urgent care need and the surgery cannot help you at the surgery or over the phone, we may ask you to call NHS 111 and they will put you in touch with a local service. This may be a face to face appointment with a local healthcare professional or a home visit where necessary. In these circumstances you will need to provide our practice details to the urgent care provider to allow them to transfer your consultation data to us so that we can update your records. If your health requirements or practical circumstances change and it is our professional oppinion that we are unable to continue to provide appropriate clinical care, you will be required to register at a practice closer to home. A parent or guardian must sign an individual declaration on behalf of any dependents under the age of 16 years. The individual will then be required to sign their own declaration at their 16th birthday if they wish to remain registered with us.Signature