Online Services

Family Doctor Services Registration

Please fill in all questions marked with a * then expand and fill in further sections relevant to you.

Patients Details

Mr Mrs Miss Ms

*Name: *Surname: Previous Surnames: *Date of Birth (dd/mm/yy):

*Gender: Male Female

NHS no.: *Town and Country of Birth: *Home Address: *Home Postcode: *Telephone Number: Email: *Ethnicity: *Language:

Please help us trace your previous medical records by providing the following information

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*Your Previous Address in the UK: *Name of previous doctors while at this address: *Address of your previous doctor:

If you are from abroad

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Your first UK address where registered with a GP: If previously resident in UK, date of leaving (dd/mm/yy): Date you first came to live in UK (dd/mm/yy):

If you are returning from the Armed Forces

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Address before enlisting: Enlistment Date (dd/mm/yy): Service or Personnel Number:

If you are registering a child under 5

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Please register the child with the doctor for Child Health Surveillance

If you need your doctor to dispense medicines and appliances*

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* Not all doctors are authorised to dispense medicines

I live more than 1 mile in a straight line from the nearest chemist

I would have serious difficulty in getting them from a chemist

NHS Organ Donor Registration

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I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death

Please tick the boxes that apply.

Any of my organs and tissue

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

For more information, please ask at reception for an information leaflet, visit the website www.uktransplant.org.uk or call
0845 60 60 400

NHS Blood Donor Registration

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I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

Tick here if you have given blood in the last 3 years.

For more information, please ask for the leaflet on joining the NHS Blood Donor Register.

My preferred address for donation is: (only if different drom the above, e.g. your place of work): Postcode:

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(Characters are not case sensitive):

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