Fields marked '*' are compulsory. You should only send this form if you are sure that you are eligible to join this practice. 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.
Last Updated: 12/07/2022
Next of Kin
Please help us trace your previous medical records by providing the following information
If you are from abroad
What is your country of birth and ethnic group?
Please tick one box that best describes your ethnic group or background from the options below:
Housing and Empolyment
These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and services.
NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC)
Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK. If you are visiting from another EEA country and do not hold a current EHIC, you may be billed for the cost of any treatment received outside the GP practice, including at hospital).
Were you or are your family part of the Armed Forces
These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.
Carer / Cared for
Family Medical History
Your Medical History