Personal details

This form should only be used if you will be in the area for more than 3 months. If you will be in the area for less than 3 months, please complete a temporary resident form.

Is this your first registration with a GP Practice in the UK?
Yes
No

Title

Surname

Forenames

Previous Surname

Date of birth

Day

Month

Year

Sex at birth
Female
Male

Address 1

Address 2 (optional)

City

Postcode

Telephone number (optional) #

Mobile number (optional) #

Email address (optional) #

# the data supplied in these fields will not be input to, or updated in, the Community Health Index (CHI), but will be heald on the GP Practice’s system.

The following information can be found on your current medical card:

Community Health Index (CHI) number (optional)

NHS number (optional)

The following information can be found on your birth certificate:

Town of birth

Country of birth

Registered district of birth - Scotland only (optional)

Mother’s maiden name (optional)

Next of Kin

Name (please include first and last name)

Contact telephone number

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