Guidelines: 

It is very important that this form is filled in accurately or this may mean a delay in receiving your medical records. 

PATIENTS DETAILS

Title – Mr Mrs Miss Ms – Tick the appropriate box according to your marital status.

Surname – Surname or Family name. Please make sure the spelling given, is the same that appears on your passport, driving licence or home office paper work.

Date Of Birth – The date you were born. 

First Names – First name or Forename. Please make sure the spelling given, is the same that appears on your passport, driving licence or home office paper work.

Previous Surname/s – If you are married please state your maiden name or if you have changed your Surname/Family name at any time please state your previous Surname/Family name.

NHS Number – If you know your NHS Number which can be found on a medical card.

Male / Female – Please tick the appropriate box.

Home Address – Please enter clearly your full postal address. 

Post Code – You need to print clearly a full post code.

Telephone Number – Please enter as many forms of contacting yourself by phone.

Your Previous Address in UK – If you were previously registered with a GP Practice then please write the address you were living at when registered. 

Name of previous Doctor while at that address – Please state the Doctors name within the GP Practice where you were registered.

Address of previous Doctor – Please state the area where the GP Practice was.

IF YOU ARE FROM ABROAD – Your first UK address where registered with a GP,  Date of leaving  and Date you first came to live in UK – 

IF YOU ARE RETURNING FROM THE ARMED FORCES

Address before enlisting – Please state the address where you were last registered with a GP practice before enlisting.

Service or Personnel number – This can be found on your Discharge Papers.

Enlistment Date – This can be found on your Discharge Papers.

If you want to be added to the NHS Organ Donor Register, and/or NHS Blood Donor Register, please complete that section.