STONYHILL MEDICAL PRACTICE

How Do I.... Register With The Practice?

Please register at the surgery.

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REGISTER DETAILS   Title: Please select Mr Mrs Miss Dr Proff Other (please specify) Date of Birth: Town & country of Birth: NHS no. (if known): Sex: Please select Male Female Surname: First Names: Telephone: Mobile: How you describe your ethnic origin? Email Address: Address:   Postcode: Are you a carer for a sick/elderly person(s)? Please select Yes No Previous medical records Your previous address in the UK   Postcode Name of your previous doctor at that address Address of previous doctor Are from abroad? Please select Yes No Your first UK address where registered with a GP If previously resident in the UK, date of leaving Date you came first came to the UK Are returning from the Armed Forces? Please select Yes No Address before enlisting   Service/Personnel No.:   Enlistment date: NHS Organ Donor Registration I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death. Please select Yes No Please check as appropriate:- Kidneys Heart Liver Corneas Lungs Pancreas Any part of my body CONFIDENTIALITY - TERMS AND CONDITIONS: The internet is not secure, and the transmission of this data is entirely at the patient's own risk. The practice accepts no responsibility for breaches in confidentiality resulting from patients' transmissions. I accept the terms and conditions above On receipt of your completed application, we will send you a pack with details of our practice and contact you to organise a new patient check.