Application to Register - ADULTS (18+)

Application to Register - ADULTS (18+)

Fields marked REQUIRED are compulsory. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Your details will be kept at the surgery and must be signed by you during your first appointment. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register

  • Personal Details

    TITLE
    DATE OF BIRTH
    For example, 15 3 1984
    SEX
    ETHNICITY

  • IF YOU HAVE HAD A GP IN THE UK BEFORE

    Please make sure you fill in all details below as if there is any missing information you will not be registered.

  • IF YOU ARE FROM ABROAD

    This section is to be fill out if you had not had a GP in the UK before. Please make sure you fill in all details below as if there is any missing information you will not be registered.

    DATE YOU FIRST CAME TO LIVE IN THE UK (optional)
    For example, 15 3 1984

  • If you have served in the British Armed Forces

    Please make sure you fill in all details below as if there is any missing information you will not be registered.

    ENLISTMENT DATE (optional)
    For example, 15 3 1984
    ARE YOU A RESERVIST? (optional)
    LEAVING DATE (optional)
    For example, 15 3 1984
    IS THIS YOUR FIRST REGISTRATION WITH A GP SINCE LEAVING THE ARMED FORCES? (optional)

  • PATIENT DECLARATION

    I declare that the information I have given on this form is correct and complete. I understand that, if it is not, appropriate action may be taken. To enable NHS National Services England to confirm my eligibility to lawfully register with a GP and for the purposes of prevention, detection, and investigation of crime, relevant information from this form will be disclosed to the NHS Business Services Authority, NHS National Services England, the Home Office, Identity and Passport Service, HM Revenue and Customs, the General Register Office and Local Authorities.

    DATE (optional)
    For example, 15 3 1984

  • Privacy and security

    Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of registration. Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.

    ARE YOU A SMOKER

  • CURRENT COVID SITUATION - IMPORTANT INFORMATION

    Currently due to the COVID situation you are not required to come into the surgery to sign these documents, as long as you have been filled in the required information you will be registered. Once you have been registered you will get a text or email to confirm your registration. It can take upto 72 working hours to be registered, if you have not received a text or email in that time frame please send us an email on blackfriarsmedicalpractice@nhs.net . Please make sure not to call the practice unless it is urgent, please send any queries on ASKMYGP or email. Thank you

  • NEW PATIENT QUESTIONNAIRE

    We need you to fill out the following information

    MARITAL STATUS
    RELIGION
    WHICH OF THE FOLLOWING BEST DESCRIBE HOW YOU THINK OF YOURSELF
    IS YOUR GENDER THE SAME AS WERE GIVEN AT BIRTH
    SEXUAL ORIENTATION
    DO YOU CONSIDER YOURSELF TO HAVE A DISABILITY
    IF YES TO THE ABOVE QUESTION: (optional)
    HAVE YOU EVER SERVED IN THE ARMED FORCES
    DO YOU COME FROM A COMMUNITY KNOWN TO PRACTICE FGM
    HAVE YOU UNDERGONE FGM
    DO YOU HAVE ANY CHILDREN AT RISK OF FGM
    DO YOU REQUIRE ANY OF THE FOLLOWING
    DO YOU HAVE ANY CHILDREN/DEPENDENTS
    CHILD 1 DATE OF BIRTH (optional)
    For example, 15 3 1984
    CHILD 2 DATE OF BIRTH (optional)
    For example, 15 3 1984
    DO YOU HAVE ANY CARING RESPONSIBILITIES
    DO YOU USE DRUGS
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Page last reviewed: 28 May 2021
Page created: 13 January 2021