Heatherlands Medical Centre

New Hey Road, Woodchurch CH49 9DA
Tel: 0151 677 2172 Fax: 0151 678 1242

Application to register with a General Medical Practitioner

Click here to open the GP Registration Form.

Application to Register With a General Medical Practioner

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

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

3. If you are abroad

4. If you are returning from the armed forces

7. NHS Organ Donor Registration

8. NHS Blood Donor Registration

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)