Please complete both forms on this page. Please not that the GMS1 form is mandatory to register.

Contents

Step 1 – GMS1 Form

Step 2 – Child Registration Form

Step 1 – GMS1 Form

Title:

Mrs

Miss

Other

NHS Number (if known)

Surname: *

First Names: *

Prev Surname:

Date of Birth: *

Sex:

Male

Female

Ethnicity: *

First Spoken Language: *

Town and Country of Birth *

Address *

Address

Postcode

City

Country

Contact Number: *

Email Address: *

Are you from/already live within the UK? *

Yes

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

Your previous address in the UK *

Your previous address in the UK

Postcode

City

Country

Name of doctor while at that address *

Address of previous doctor *

Address of previous doctor

Postcode

City

Country

If you are from abroad:

Your first address where registered with a GP *

Your first address where registered with a GP

Postcode

City

Country

If previously resident in UK, date of leaving *

Date you first came to live in the UK *

If you are from the Armed Forces:

Address before enlisting

Postcode

City

Country

Service or Personnel number

Enlistment date

Discharge date

If registering a child under 5:

I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance.

If you need your doctor to dispense medicines and appliances * :

* 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 the chemist.

NHS Organ Donor registration:

I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death.

Please tick as appropriate:

Any part of my body

Or only my:

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

NHS Blood Donor registration

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.

Emergency Contact

Name:

Relationship:

Contact Number:

Address:

Postcode

City

Country

I have filled in this form on behalf of

Step 2 – Child Registration Form

Registration Form (Child)

New Patient Registration Form

Please Note: A supporting signed letter from the patient will be required either posted or emailed to the practice, to complete the registration.

1. Background Details

Your Child’s Details

NHS Number (if known)

Child Name *

Gender

Date of Birth *

Address *

Address

Postcode

City

Country

Home Telephone *

Parent or Guardian Details

Your Name *

Relationship *

Address *

Address

Postcode

City

Country

Home Telephone

Work Telephone

Mobile Number *

I consent to be contacted* by SMS on this number

Email *

I consent to be contacted* by email at this number

Family Registered with Us

* It is your responsibility to keep us updated with any changes to your telephone number, email & postal address. We may contact you with appointment details, test results, health campaigns or Patient Participation Group details. If you do not consent to being contacted by SMS or Email, please tick here:

SMS

Other Details

Previous GP

Name *

Address *

Address

Postcode

City

Country

Country of Birth *

Ethnicity

White (UK)

White (Irish)

White (Other)

Black Caribbean

Black African

Black Other

Bangladeshi

Indian

Pakistani

Chinese

Other

Religion

Housing

Overseas Visitor

Yes

European Health Insurance Card Held (please bring details with you)

Armed Forces

Family member

Communication Needs

Language

What is your main spoken language?

Do you need an interpreter?

Yes

Communication

Do you have any communication needs?

Yes

Please specify below

Hearing aid

Lip reading

Large print

Braille

British Sign Language

Makaton Sign Language

Guide dog

Learning disability

Do you have a Learning Disability?

Yes

(If yes please request a Learning Disability Screening Tool form)

If you are human, leave this field blank.