Registering with the surgery

Mr

Mrs

Miss

Ms

Name

First

Last

Date of Birth:

Please use this date format: DD/MM/YYYY.

Previous Name

First

Last

NHS Number

Gender

Male

Female

Indeterminate

Town and country of birth:

Phone

Home Address:

Postcode:

Your previous address in the UK (Please help us trace your previous medical records by providing the following information):

Date you first came to live in UK:

Please use this date format: DD/MM/YYYY.

If previous resident in UK, date of leaving:

Please use this date format: DD/MM/YYYY.

If you are returning from the armed forces

Service or personnel number:

Enlistment date:

Please use this date format: DD/MM/YYYY

If you are registering a child under 5

I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance

If you need your doctor to dispense medicines and appliances*

*Not all doctors are authorised to dispence medicines

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

NHS Organ Donor registration

For more information, please ask at reception for an information leaflet or visit the website www.uktransplant.org.uk, or call 0300 123 23 23.

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please select all that apply:

NHS Blood Donor registration

For more information, please ask for the leaflet on joining the NHS Blood Donor Register

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

I have given blood in the last 3 years

Signature confirming consent to inclusion on the NHS Blood Donor Register

European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea

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

Signature

Signature of behalf of Patient

Date

Supplementary Questions

I am not ordinarily a resident in the UK