Application to register with a General Medical Practitioner

Fields marked with an asterisk are compulsory. 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 download the PDF form, fill it and email to [email protected]. Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.

1. Patient’s Details – Please complete the text boxes and tick where appropriate

Title*

First Name*

Surname*

Previous Surname

Date of Birth* e.g. 01/01/2018

Gender*

NHS NO.

Birth Town*

Home Address*

Birth Country*

Telephone*

Postcode*

I am student at

2. Please help us trace your previous medical records by providing the following

Your Previous Address in UK

Name of Previous GP

Address of that Doctor

3. If you are abroad

Your first UK address where registered with a GP

Date of Leaving

Date you first came

4. If you are returning from the armed forces

Address before enlisting

Service Personal No.

Enlistment Date

5. If you are registering a child under 5

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

6. If you need your doctor to dispense medicines and appliances

7. NHS Organ Donor Registration

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 tick the boxes that apply:

8. NHS Blood Donor Registration

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

Tick here if you have given blood in the last 3 years

For more information, please ask for the leaflet on joining the NHS Blood Donor Register Preferred address for donation: (if different from above, e.g. place of work)

Heatherlands Medical Centre

Application to register with a General Medical Practitioner

Contact Details

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