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

Family Name

Date of Birth

Gender

Address

Contact Number

Email Address

Place of Birth

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

What is your Ethnic Group?

White British

White Irish

White Other

Black Caribbean

Black African

Black Other

Indian

Pakistani

Chinese

Other Asian

White + Black Caribbean

White + Black African

White + Asian

Other

Name of Next of Kin

Relationship

Contact Information for Next of Kin

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

Yes

No

Details of Previous GP

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

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?

How many units of alcohol do you have per week?

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

Yes

No

Signature

Date

Comments

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