* Required Field are marked with an asterisk

Patient Details

Title*:

Surname*:

First names*:

Previous surname(s):

Date of Birth*:

Sex*:

NHS Number*:

If you do not know your NHS number, please click on this link, which should open a new window NHS Number

Town and country of birth*:

Home address 1*:

Home address 2:

Home address 3:

Postcode*:

Primary Telephone number*:

Secondary Telephone number:

Email:

 


Tracing your medical records

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

Previous address in UK*:

Previous address in UK Postcode*:

Name of previous practice*:

Previous Doctor address:

Previous Doctor Postcode*:

 


If you are from abroad:

Abroad address:

If previously resident in UK, date of leaving:

Date you first came to live in UK:

 


If you are returning from the Armed Forces:

Enlisting Address:

Enlisting Postcode:

Service or Personnel number:

Enlisting date:

 


If you need your doctor to dispense medicines and appliances

 I live more than 1 mile in a straight line from the nearest chemist

 I would have serious difficulty in getting them from a chemist

 


Patient Signature

 I confirm I am registering as the patient, or on behalf of the patient above

 


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:

 Kidneys  Heart  Liver  Corneas  Lungs  Pancreas  Any part of my body

 


NHS Blood Donor Registration

I would like to join the NHS Blood Donor Register as soemone who may be contacted and would be prepared to donate blood

 Tick here if you have given blood in the last 3 years

 I confirm consent to inclusion on the NHS Blood Register

 


Ethnicity

Ethnicity*:

If Other please specify:

 

Home Visits

Please note, patients outside the following postcodes are not eligible for a home visit:
• Small Heath site: B9, B10, B11
• Finch Road/Lozells site: B6, B19, B20

By completing this form you agree to the above for all persons registered at the same address. Home visits are only available for housebound patients, at the GP’s discretion.

Please note, registration can take up to 10 working days. Please contact the practice if you have not had confirmation within 10 working days.