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

Last Updated: 28/05/2021

Personal Details

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.

PREVIOUS FULL ADDRESS IN THE UK (INCLUDING POSTCODE)

NAME OF PREVIOUS GP PRACTICE

ADDRESS OF PREVIOUS GP

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

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

SERVICE NUMBER

ARE YOU A RESERVIST?

YES

IF YES, PLEASE PROVIDE YOUR ADDRESS BEFORE ENLISTING

POSTCODE

LEAVING DATE

IS THIS YOUR FIRST REGISTRATION WITH A GP SINCE LEAVING THE ARMED FORCES?

YES

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.

PATIENT'S / PATIENT'S REPRESENTATIVE SIGNATURE: (YOU WILL NEED TO SIGN THIS AT THE PRACTICE AFTER COVID)

DATE

REPRESENTATIVE'S NAME (IF APPLICABLE)

RELATIONSHIP TO PATIENT (IF APPLICABLE)

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 *

YES

IF YES, HOW MANY A DAY *

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

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Application to Register - ADULTS (18+)

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