Temporary patient registration

Patient’s details

Please specify:

Surname: *

Previous Surnames:

First Name(s) *

Date of Birth: *

Please use this date format: DD/MM/YYYY

Sex: *

Male

Female

Other

NHS Number:

Your NHS number is a 10 digit number that you find on any letter the NHS has sent you. For example, 485 777 3456.

Town and Country of birth: *

Home Address: *

Postcode: *

Email Address: *

Any responses we send will go to this email address

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

Full temporary address:

Full temporary postcode:

Your current GP Surgery:

With full address if possible

Do you have any urgent medical needs today?

Yes

No

If yes, you should also contact the surgery as soon as possible

Medical questionnaire

What pharmacy would you like your prescriptions to go to?

NHS UK: Find a pharmacy

Regular medication:

Please list names of all tablets, medicines, creams etc. with dosage or times used:

Please specify:

Allergies

Do you have any allergies? *

Yes

No

Please specify what you are allergic to, what happens and when you had your first reaction:

Lifestyle

Height:

Weight:

Smoking Status: *

Current Smoker

Ex Smoker

Never Smoked

How many do you smoke per day?

How many did you smoke per day?

When did you stop?

Emergency contact

Full Name: *

Relationship to you: *

Phone Number: *

Are they your next of kin? *

Yes

No

Carers

Do you have a carer? *

Yes

No

Are you a carer for someone?

Yes

No

Name of carer:

Phone Number:

Address:

Carer’s relationship to you: