EHIC Application

Just complete this form, make your payment online, and leave the rest to us:

Personal information
Title *	please select: Mr Mrs Miss Ms Dr Prof Other
Family name *
First (given) name *
Birth date *	(DD/MM/YYYY)
NHS or NI No.*
EHIC PIN Number (Only for Renewals)
Are you planning to permanently live outside the UK after this visit? *	Yes     No
If Yes, enter expected departure date.
Contact Details
House Name or Number *
Street *
Town *
County *
Postcode *
Country *	please select: England Scotland Northern Ireland Wales
E-mail address *
Please re-enter your E-mail address *
Telephone no. *
Add details for Spouse/Partner

Title	please select: Mr Mrs Miss Ms Dr Prof Other
Family name
First (given) name
Birth date	(DD/MM/YYYY)
NHS or NI No
EHIC PIN Number (Only for Renewals)

Add details for First Child

Title	please select: Master Miss Other
Family name
First (given) name
Birth date	(DD/MM/YYYY)
NHS or NI No.
EHIC PIN Number (Only for Renewals)

Note: For dependent children, if you do not know the child's NHS or NI number, please give that of the Main Applicant

Add details for Second Child

Title	please select: Master Miss Other
Family name
First (given) name
Birth date	(DD/MM/YYYY)
NHS or NI No.
EHIC PIN Number (Only for Renewals)

Note: For dependent children, if you do not know the child's NHS or NI number, please give that of the Main Applicant

Add details for Third Child

Title	please select: Master Miss Other
Family name
First (given) name
Birth date	(DD/MM/YYYY)
NHS or NI No.
EHIC PIN Number (Only for Renewals)

Note: For dependent children, if you do not know the child's NHS or NI number, please give that of the Main Applicant

Add details for Fourth Child

Title	please select: Master Miss Other
Family name
First (given) name
Birth date	(DD/MM/YYYY)
NHS or NI No.
EHIC PIN Number (Only for Renewals)

Note: For dependent children, if you do not know the child's NHS or NI number, please give that of the Main Applicant

Declaration: I agree that I have British, EU, EEA or Swiss nationality. I agree that all persons to be specified in this application are UK residents. I declare that the persons named have consented to their personal details being disclosed. I declare that the Main Applicant is 16 years or over. The information that I have given on this form is correct and complete to the best of my knowledge. I understand that should any person on this application decide to remain abroad to live or work, then the relevant authorities must be informed and the EHIC returned. I understand that this card is not an entitlement card for NHS services, or proof of identity.
Please read our TERMS & CONDITIONS and our PRIVACY POLICY
I have read and agree to the above Declaration *	YES
Please select service level required *	EXPRESS	(Processed immediately, allow 7-10 days delivery - £19.99)
	STANDARD	(Processed within 24 hours, allow 2 weeks delivery - £14.99)
Click on the button opposite to send the form. You will then be taken to the payment section.