Application to Register with a General Medical Practitioner

About This Form

Fields marked with a red asterisk are
compulsory.

You should only send this form if you are sure that you are eligible to join this practice.
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 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 that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of registration.

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.


Patient's Details - Please complete the text boxes and tick where appropriate
Title	Mr Mrs Miss Ms	Surname
Date of Birth		First Name
NHS No.		Previous Surname
Sex	MaleFemale	Town & Country of Birth
Home Address		Postcode
Home Address		Telephone
I am a student at:

Please help us trace your previous medical records by providing the following
Your previous address in UK	Name of previous GP while at previous address
	Address of that Doctor
If you are from abroad
Your first UK address where registered with a GP	If previously resident in UK, date of leaving
	Date you first came to live in UK
If you are returning from the armed forces
Address before enlisting	Service or Personnel Number
	Enlistment date
If you are registering a child under 5
I wish the child above to be registered with the named doctor for Child Health Surveillance
If you need your doctor to dispense medicines and appliances
I live more than 1 mile in a straight line from the nearest chemist
I would have serious difficulty in getting them from a chemist