Patient registration form - Stoke Gifford & Conygre Medical Centre

Patient's details

Title*

Mr
Mrs
Miss
Ms

Surname*

Date of birth*

First names*

NHS Number*

Previous surnames

Gender*

Male
Female

Town and country of birth*

Home address*

Postcode*

Telephone number*

Email address

Enter Email Confirm Email

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

Your previous address in UK

Name of previous GP practice while at that address

Address of previous GP practice while at that address

If you are from abroad

Your first UK address where registered with a GP

If previously resident in UK, date of leaving

Date you first came to live in the United Kingdom

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

Regular
Reservist
Veteran
Family Member (Spouse, Civil Partner, Service Child)

Address before enlisting

Service or Personnel number

Postcode

Enlistment date

Discharge date (if applicable)

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 authorised to dispense medicines

I live more than 1.6km in a straight line from the nearest chemist
I would have serious difficulty in getting them from a chemist

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.

Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision.

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.

Yes I would like to join the NHS Blood Donor Register
Tick here if you have given blood in the last 3 years

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

All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.

Contact preference consent*

I agree that I may be contacted from time to time, via email and/or SMS with practice news, advice about my health and/or appointment reminders.

Yes I consent
No

Consent*

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.

I agree to the privacy policy.

Name

This field is for validation purposes and should be left unchanged.