New Patient Registration

Who is Registering?

Are you registering: *

NHS Blood and Organ Donor Registration

You can help save lives as a blood or organ donor. Become someone’s lifeline.

Visit www.nhsbt.nhs.uk/lifeline or call 0300 123 23 23

Details of Patient Registering

Title *
Please use this date format: DD/MM/YYYY
Sex: *
(As recorded on your NHS record)
Do you have a fixed address? *

Previous Details

Please put N/A if not applicable.
Please include postcode. Please put N/A if not applicable.
Have you ever lived somewhere else in the UK? *
Please include postcode.

Patient’s Contact Details

The NHS and your GP surgery can use the following details to call, text or email you about health care services. All phone numbers must be registered in the UK.

Please put N/A if not applicable.
Please put N/A if not applicable.
Please put N/A if not applicable.
Any responses we send will go to this email address.

Emergency Contact

Are they your next of kin? *

Next of Kin

Patients Under 18 Years

Is the patient under 18 years? *
Is the patient under 12 months? *
Please include postcode.

Did you attend any of the following?
Are any of these involved in your care?
Have you had all your routine vaccinations? *
Did you get your routine vaccinations in the UK? *

Additional Information

Please specify the ethnic group you consider you belong to: *
Have you registered with a UK GP before? *

If you are from abroad

Registering with the NHS for the first time in the UK
Have you moved to the UK and are registering with the NHS for the first time? *
Please use this date format: DD/MM/YYYY

If you are returning from abroad

Previously been registered with the NHS in the UK
Have you moved back to the UK and have previously been registered with the NHS? *
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY

Have you ever served in the UK Armed Forces or were you ever registered with a Ministry of Defence GP in the UK or overseas? *

If you were given a FMED133A form (sometimes called an FMED1 form) when you left the UK Armed Forces, you should give this to your GP surgery.

Do you need an interpreter for your appointments? *
Please specify if you need a BSL interpreter:

Carers

Are you a carer? *
What type of carer are you? *
Do you have a carer? *
What type of carer are they? *

Nominated Pharmacy

What pharmacy do you want your prescriptions sent to?
Please include postcode.

Summary Care Record

Do you want important information from your GP record to be available to other health and care professionals?

You GP surgery needs permission to share important information from your GP record. This is called a Summary Care Record (SCR). You SCR can only be shared with health and care staff across England who are providing you with direct care. It gives access to vital information from your GP record.

Please specify your Summary Care Record choice: *