JF001 - Premier Registration

Registration Form

Please fill in the short form below.
Patient details
Who are you registering for? *
Relation with patient *
Please enter your relation with the patient
Full Name *

Prefix First Name Last Name
Gender *
Date of Birth *

Day Month Year
Mobile Number *
Home Number
E-mail *
Confirm E-mail *

Getting to know you better
NHS Number (If Known, 10 digits, no spaces)
Your NHS number is a 10 digit number, like 485 777 3456.

If you do not remeber your NHS number, use this service to find your NHS number

If you cannot get your NHS number online you can:
- find it on any letter from the NHS like a prescription or appointment letter
- call your GP surgery and ask them for your number
Home Address *
Main Language spoken *

English Other
Please choose the language *
Do you need an interpreter? *

Yes No
Ethnicity *
Were you born in the England? *

Yes No
Please enter you country of birth
Date you first came to live in the U.K. *