Harptree Cameley Surgery - Family doctor services registration (GMS1)

Family doctor services registration
GMS1
Patient's details*

MrMrsMissMs
First name/s*
Surname*
Previous surname/s
Date of birth*

DayMonthYear
Date
NHS No. (if known)
Gender*

MaleFemale
Nationality*
Town and country*
Home Address

Street Address

Street Address Line 2

CityCounty

Post Code
Telephone Number*
Home number (Please enter telephone number if you have no home number)*
Email Address*
Do you consent to being contacted by text and email?*

YesNo
If you require a personal translator, can you confirm they can speak/read English?

YesNo
Emergency contact/next of kin details
Full Name*

First NameLast Name
Relationship to you?*
Contact Number*
Please help us trace your previous medical records by providing the following information.
Address

Street Address

Street Address Line 2

CityCounty

Post Code
Name of GP practice while at that address
Address of previous GP practice

Street Address

Street Address Line 2

CityCounty

Postcode
If you are from abroad, your first UK address where you registered with a GP

Street Address

Street Address Line 2

CityCounty

Post Code
If previously resident in UK, date of leaving

DayMonthYear
Date
Date you first came

DayMonthYear
Date
Were you ever registered with an Armed Forces GP
Please indicate if you have served in the UK Armed forces and/or been registered with a Ministry of Defence GP in the UK or overseas

RegularFamily Member (Spouse, Civil Partner, Service Child)VeteranFamily Member (Spouse, Civil Partner, Service Child)
Address before enlisting

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Service or Personnel number:
Enlistment date:

DayMonthYear
Date
Discharge date:

DayMonthYear
Date
Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.
If you need your doctor to dispense medicines and appliances

I live more than 1.6km in a straight line from the nearest chemistI would have serious difficulty in getting them from a chemist
Signature of patient

Clear
Signature on behalf of patient

Clear
Date of signature

DayMonthYear
Date
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.

Any of my organs and tissue orKidneysHeartLiverCorneasLungsPancreas
Date

DayMonthYear
Date
Signature confirming my consent to join the NHS Organ Donor Register

Clear
Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.ul or call 0300 123 23 23 to register your decision.
NHS Blood Donor registration Iwould like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

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

DayMonthYear
Date
Signature confirming my consent to join the NHS Blood Donor Register

Clear
My preferred address for donation is: (only if different from above, e.g. your place of work)

Street Address

Street Address Line 2

CityCounty

Postcode
All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.
Patient registered for

GMSDispensing
Should be Empty: