Register as a patient form

Patient's details

Please complete the text boxes and tick where appropriate

Your title

Mr

Mrs

Miss

Ms

Surname

First name(s)

Previous surname

Your date of birth

Sex

Male

Female

Birth town

Birth country

Telephone

NHS No.

An NHS number is a 10-digit number, like 485 777 3456. If known, please enter your NHS number in the field below. You can find more information on the NHS website

Home address

Postcode

I am a student at:

If applicable, please enter the name of the educational institution you are attending in the field below

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

Your first UK address where registered with a GP

If previously resident in UK, date of leaving

Date you first came to live in UK

Were you ever registered with an Armed Forces GP

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:

Regular

Reservist

Veteran

Family Member (Spouse, Civil Partner, Service Child)

Address before enlisting

Postcode before enlisting

Service/Personnel No.

Enlistment date

Discharge date (if applicable)

If you need your doctor to dispense medicines and appliances

Do 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

Are you a patient?

I am a patient

I am filling the form on behalf of a patient

Date

Please enter the date of submitting the application below