Application to Register with a General Medical Practitioner

Patient's Details - Please complete the text boxes and tick where appropriate

Title

Surname

First Name(s)

Previous Surname

Birth Town

Birth Country

Telephone

I am a student at:

Date of Birth

NHS No.

Sex

Male Female

Home Address

Postcode

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/Personnel No.

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

Signature of patient

Signature on behalf of patient

Date:

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.
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.