290 Knowsley Road, Bootle, Merseyside, L20 5DQ
Tel: 0151 922 3841
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Application to Register with a General Medical Practitioner
Patient's Details - Please complete the text boxes and tick where appropriate
Title:
Surname: *
First Name(s): *
Previous Surname: *
Date of Birth: *
NHS No.:
Sex: Male Female
Home Address: *
Birth Town: *
Telephone: *
Postcode: *
I am student at:
Email: *
Confirm Email: *
Please help us trace your previous medical records by providing the following
Your previous address in UK:
Name of previous GP while at previous address:
Address of that Doctor:
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 UK
If you are returning from the armed forces
Address before enlisting:
Service/Personnel No.:
Enlistment date:
If you are registering a child under 5
I wish the child above to be registered with the named doctor for Child Health Surveillance
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
Signature of patient          Signature on behalf of patient
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 Corneas Lungs Pancreas
Any part of my body
NHS Organ 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.
 
   
For more information, please ask for the leaflet on joining the NHS Blood Donor Register Preferred address for donation: (if different from above, e.g. place of work)
Postcode:
   
 
About This Form
Fields marked with a red asterisk 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 held at the surgery for a limited period of time. You are required to present in person to sign your registration form and provide proof of your address
  • Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register
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
Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.
 
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