Family doctor services registration GMS1 Patient's details * Mr Mrs Miss Ms Surname * Date of birth * / Day / Month Year Date First names * NHS No. Gender * Male Female Previous surname/s Town and country * Home Address Street Address Street Address Line 2 City County Post Code Telephone number * Please help us trace your previous medical records by providing the following information. Address Street Address Street Address Line 2 City County Post Code Name of GP practice while at that address Address of previous GP practice Street Address Street Address Line 2 City County Postcode If you are from abroad, your first UK address where you registered with a GP Street Address Street Address Line 2 City County Post Code If previously resident in UK, date of leaving - Day - Month Year Date Date you first came / Day / Month Year Date Were you ever registered with an Armed Forces GP Please indicate if you have served in the UK Armed forces and/or been registered with a Ministry of Defence GP in the UK or overseas Regular Family Member (Spouse, Civil Partner, Service Child) Veteran Family Member (Spouse, Civil Partner, Service Child) Address before enlisting Street Address Street Address Line 2 City State / Province Postal / Zip Code Service or Personnel number: Enlistment date: / Day / Month Year Date Discharge date: / Day / Month Year Date Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services. If you need your doctor to dispense medicines and appliances I live more than 1.6km in a straight line from the nearest chemist I would have serious difficulty in getting them from a chemist Signature of patient Clear Signature on behalf of patient Clear Date of signature / Day / Month Year Date NHS Organ Donor registration - I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply. Any of my organs and tissue or Kidneys Heart Liver Corneas Lungs Pancreas Date / Day / Month Year Date Signature confirming my consent to join the NHS Organ Donor Register Clear Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.ul or call 0300 123 23 23 to register your decision. NHS Blood Donor registration Iwould like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood. Tick here if you have given blood in the last 3 years Date / Day / Month Year Date Signature confirming my consent to join the NHS Blood Donor Register Clear My preferred address for donation is: (only if different from above, e.g. your place of work) Street Address Street Address Line 2 City County Postcode All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23. Patient registered for GMS Dispensing Preview PDF Submit Should be Empty:
