Registration Forms

If you wish to register with us, please fill out the below Registration Form.

Click on the link below to open the Registration Form. When you have completed all of the details, click on the “Send” button to mail your form to us.

PATIENT REGISTRATION FORM

Title

Given Name(Required)

Family Name(Required)

Date of Birth(Required)

NHS Number(Required)

Gender

Address(Required)

Previous Address(Required)

Contact Number(Required)

Email Address

Ethnicity

Do you consent to being contacted by Hampton Hill Medical Centre via email and/or SMS?

Yes

No

Have you previously been registered with an NHS GP in the UK?(Required)

Yes

No

Details of Previous GP

Place of Birth(Required)

If outside the UK, what was the date you arrived in the UK?

Are you currently a Refugee in the UK?

Yes

No

Name of Next of Kin

Relationship

Contact Information for Next of Kin

Are you returning from the Armed Forces?

Yes

No

Are you a Carer?

Yes

No

If yes, please give details.

Do you have a Carer?

Yes

No

If yes, please give details.

Height

Weight

Blood Pressure

How many units of alcohol do you have per week?

Have you ever smoked?

Yes

No

If you are a current smoker, how many per day?

If you are an ex-smoker, what year did you stop?

Do you want access to your Online Medical Record?

Yes

No

Please upload an image of your Photographic ID(Required)

Max. file size: 63 MB.

Signature(Required)

Date

Name

This field is for validation purposes and should be left unchanged.