Application For Inclusion in a Practice List and/or Health Service Registration

Part A: Applicant Details
Surname ++Was child know by any other surname? Forname(s) Male/Female Date of Birth Country of Birth
++If any child was known by another surname, please complete and send us form GMF153, available from the practice

About This Form

Fields marked with a red asterisk are

Guidance Notes

Please read the following notes very carefully before completing the form. Please note that to secure inclusion in a practice list, the completed form should be given to the chosen practice for acceptance.

This form must be completed by or on behalf of all persons (except those referred to below) who wish to register under the Health Service in Northern Ireland for General Medical and/or General Dental and General Ophthalmic Services and who are currently resident in Northern Ireland.

Persons not required to complete this form

  • Persons ordinarily resident in Northern Ireland who have misplaced their valid Northern Ireland Medical Cards or persons who have come to Northern Ireland directly from residing in England, Scotland or Wales also use form HS200 to register with a doctor. This is available at any Doctor's Surgery or from the address below.
  • Holders of an Infant Registration Form (HS123) issued by the Registrar when a birth is registered. If original Infant Registration Form (HS123) has been mislaid, a duplicate should be obtained from the District Registrar's Office.
  • Holders of Form FP13 issued on discharge from the HM Forces.

To secure inclusion in a practice list, the completed form should be given to the chosen practice for acceptance.

Children Under 16

This form maybe used to register children under 16 residing with the applicant provided that the full names and dates of birth of the children are entered in Part A.

If inclusion in a practice list is required, the form should be presented to the practice chosen. In all other cases, the form should be forwarded to:

The Director of Family Practitioner Services
Business Services Organisation
2 Franklin Street

If you wish your name io be recorded on the NHS Donor Register, please complete the statement at Part E.

Please note that, unless you intend to remain permanently in the UK, we need details on how long you intend to stay; otherwise we are unable to process your application.