New Students Registration Form (Coventry)

UK Residency
Are you ordinarily a resident of the UK? *

Yes No
Please select one option.

I understand that I may need to pay for NHS treatment outside of the GP practice I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge (“the Surcharge”), when accompanied by a valid visa. I can provide documents to support this when requested I do not know my chargeable status

European Economic Area (EEA) Country
Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state? *

Yes No
For a list of EEA countries visit: https://www.gov.uk/eu-eea
Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) *

Yes No
Please enter your EHIC or PRC details below
Country Code
Personal Identification Number
Identification number of the institution
Identification number of the card
Expiry Date on Card

Day Month Year
Date
PRC validity period - from:

Day Month Year
Date
PRC validity period - to:

Day Month Year
Date
Do you have an S1 Form?

Yes No

New Students Registration Form