Temporary patient registration

Patient’s details

Surname: Required

Previous Surnames:

First Name(s) Required

Date of Birth: Required

Please use this date format: DD/MM/YYYY

Sex: Required

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: Required

Home Address: Required

Postcode: Required

Email Address: Required

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?

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

Yes

Allergies

Do you have any allergies? Required

Yes

Lifestyle

Height:

Weight:

Smoking Status: Required

Current Smoker

Ex Smoker

Never Smoked

Emergency contact

Full Name: Required

Relationship to you: Required

Phone Number: Required

Are they your next of kin? Required

Yes

Carers

Do you have a carer? Required

Yes

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Patient’s details

Medical questionnaire

Allergies

Lifestyle

Emergency contact

Carers