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.
Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.
Last Updated: 09/08/2021
Please help us trace your previous medical records by providing the following
If you are from abroad
If you are returning from the armed forces
Data sharing consent choices
Please tell us about yourself
Female patients only
NHS Organ Donor Registration
NHS Blood Donor Registration
Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.
PATIENT DECLARATION for all patients who are not ordinarily resident in the UK
NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS
How will your EHIC/PRC/S1 data be used?