Home
Blog

Select Page

851

GP Surgery Registration Form

Let new patients register for a family doctor online with our customizable GP Surgery Registration Form template. This section includes an e-signature for registration along with an optional, separate signature for blood and organ donors.

Patient Name *

First

Middle

Last

Patient Phone *

If registering a child, please provide the parent or guardian's phone number.

Patient Email Address *

Confirm Email

If registering a child, please provide the parent or guardian's email address.

Gender *

Has this patient previously been known by another name?

Previous Name

First

Middle

Last

Residency

Patient's Current Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Is the patient ordinarily resident in the UK? *

Yes
No
I don't know

Please select one of the following options:

The patient understands that they may need to pay for NHS treatment
The patient has a valid exemption from paying for NHS treatment and will provide evidence on request

Being ordinarily resident means the patient is settled in the UK. If you are from outside the European Economic Area, you must also have the status of 'indefinite leave to remain'. We will contact you to discuss this in more detail.

Can the patient access a local chemist or pharmacy to collect medication? *

Yes
Yes, but they live more than 1 mile (1.6km) away
No, they would have serious difficulty

Patient's Previous Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Previous GP Details

Previous GP Surgery Name

Previous GP Surgery Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Have you ever been registered with a Ministry of Defence GP? *

Please provide your position in the Armed Forces

Regular
Reservist
Veteran
Family member

Service or Personnel Number

Enlistment date//

Discharge date//

Your Signature *

Please sign to confirm the information provided for registration.

If you are not the patient, please specify your relationship

Donor Information

The questions in this section are optional.

Patient would like to join the NHS Organ Donor Register
Patient would like to join the NHS Blood Donor Register

Patient's Signature

The patient must sign to confirm that they would like to be added to the NHS Register(s) selected above.

851

Residency

Previous GP Details

Donor Information

Recent Posts

Recent Comments