Application to Register with a General Medical Practitioner

Patient Details - Please complete the text boxes and tick where appropriate.  All questions marked with an asterisk * are compulsory.
 

*Title MrMrsMissMsOther

*Surname

*First Name 

*Previous Surname 

*Birth Town 

*Birth Country 

*Phone Number 

I am a student at

*Date of Birth 

NHS Number

Sex MaleFemale

*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

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas:

RegularReservistVeteranFamily Member-e.g.Spouse/Civil Partner/Service Child

Address before enlisting

Postcode

Service/Personnel No.

Enlistment Date

Discharge Date (if applicable)

If you need your doctor to dispense medicines and appliances

I live more than 1.6km in a straight line from the nearest chemist

I would have serious difficulty in getting them from a chemist

Signature of patient

Signature of behalf of patient

Date

Send