Please help us trace your previous medical records by providing the following information
Your previous address in the UK
Your first UK address where registered with a GP
Were you ever registered with an Armed Forces GP
Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas
Address before enlisting:
Footnote: 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.
If you need your doctor to dispense medicines and appliances*
*Not all doctors are
NHS Organ Donor registration
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.
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.
All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk
or call 0300 123 23 23.
If you are applying on behalf of a child who is in foster care/residential care/Kinship care/ or who is not your child
Who has the legal responsibility for the child?
If other is selected please supply the Name and Contact Number
If you are the parent/guardian/foster carer but cannot consent please detail below who can
Are you an Adult with social care involvement?
Summary Care Record (SCR)
The SCR is a summary of your medical history that can be shared between healthcare staff treating patients in an emergency or out-of-hours with faster access to key clinical information. More information can be found by visiting www.nhscarerecords.nhs.uk
Do you consent to receive the following types of communication from us?
Please tick for Yes and Leave blank for no.
Do you look after someone who is a patient of our Practice?
Do you have any allergies?
What are your smoking habits?
If a child, are they looked after?
If a child, are they living in a Private Fostering arrangement? (please note you have a duty to notify social care of this arrangement)
What is Private Fostering?
A private fostering arrangement is one that is made without the involvement of the Local Authority to look after a child under the age of 16 (or under 18 if disabled) by someone other than a parent or close relative, for 28 days or more and can include those living with extended family members. So, this could be a child living with people as stated below:
Private Fostering includes a child living with:
• great aunts or uncles
• family friends
• step parents where a couple isn't married or in a civil partnership
• a host family which is caring for a child from overseas while they are in education here
Private Fostering does not include a child living with:
• step parents where a couple is married or in a civil partnership
• children and young people who are being looked-after by the Local Authority
What is your ethnic group?
Please nominate a pharmacy:
So we can send your prescription direct to them
If domestic abuse is affecting your health you can speak to someone here.
Please tick this box if you would like a GP to contact you.
(Additional information includes: Social worker involved with your family; legal parental responsibilities of minor under 16 years old; applicant is in foster care or is adopted; if you are from overseas and claiming asylum or are a refugee)