Are you completing this form for a child under 16 years old?
Required
Title
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First name
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Last name
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Date of Birth
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Europe/London
NHS number (if known)
Sex at birth
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Gender
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Male Female Other
Religion
** None No religion Christianity Buddhism Hinduism Islam Judaism Sikhism Other I do not wish to state
Ethnicity
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Arab Asian or Asian British - Bangladeshi Asian or Asian British - Indian Asian or Asian British - Other Asian or Asian British - Pakistani Black or Black African Black or Black British Black or Black Caribbean Black or Black Other Gypsy or Irish Traveller Mixed - Other Mixed - White and Asian Mixed - White and Black African Mixed - White and Black British Mixed - White and Black Caribbean White - British White - Caucasian White - Irish White - Other Other - Chinese I do not wish to state
What is your main spoken language?
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Do you need an interpreter?
Do you use any of the following?
Your address
Have you lived at your current home address for more than 3 years?
If you have not lived at your current address for more than three years, please provide your previous home address
Phone number
Required
Email address
Have you previously been registered with an NHS GP?
Please provide the name and address of your previous GP
Were you born in the UK?
Required
If you were not born in the UK, when did you enter the UK?
What country were you born in?
Required
Place of birth (e.g town or city)
Required
Have your previously served in the armed forces?
Next of Kin details
Please provide your next of kin's full name, contact number and their relationship to you below.
Your information
We would like to send you text messages to your registered mobile about your healthcare. This may include things like appointment reminders and test results. Is this OK?
Required
Would you like us to send you appropriate emails from the surgery?
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Summary Care Record www.nhscarerecords.nhs.uk or call 0845 603 8510
Would you like to opt in to the Summary Care Record?
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Are you happy for us to share your full medical records electronically with other services involved in your care?
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Patient signature
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