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Globe Town Surgery
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Registration

Family doctor services registration
Please complete the following form.

Fields marked * are mandatory.

Title*
Surname*
Forenames*
Previous Surname*
Date of birth*
Town and country of birth*
Term time address*
Post code*
Telephone*
Please let us have a landline number for you where possible. All urgent communications will be made to your mobile. Non-urgent or routine matters will be contacted either via a landline number or by letter.
Work Telephone*
Please leave blank if you do not wish to be contacted at work.
Mobile*
Email address*
If you wish to be contacted via email in the future tick here
If you have not had a previous UK address click here
Please help us trace your previous medical records by providing the following information.
This section is only required if the above box is un-ticked.
Previous UK Address*
Name of previous Doctor*
Address of previous Doctor*
If you are not from abroad tick here
If you are from abroad....
Your first UK address where registered with GP*
If previously resident in UK, Date of leaving*
Date you first came to live in UK*
If you are not returning from the Armed Forces tick here
If you are returning from the armed forces....
Address before enlisting*
Service Personnel Number*
Enlistment date*
   
If you are registering a child under 5
  I wish the child above to be registered with the doctor named below for Child Health Surveillance.
   
NHS Organ Donor Registration
I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death. Please tick as appropriate.
Kidneys Heart Liver
Corneas Lungs Pancreas
Any part of my body
Signature confirming consent to organ donation:
  _____________________________________________________________
If you consent to organ donation we are required to hold your signature.
Please print this form and sign here and either post bring the form to us.
Without your signature we will not be able to apply your organ donation wishes.
Your registration with us is unaffected by whether you do or do not sign for organ donation.
   
Which doctor would you prefer to be usually seen by?
 
   
Ethnicity
We are required to ask all of our patients about their ethnicity and religion. This is because knowing a person’s ethnic group can help identify those who may be at greater risk from heart disease, diabetes or sickle cell disease. The information you provide can help our GPs make a quicker diagnosis.

What do you consider to be your ethnic origin?*
   
In which language would you most prefer us to provide a service to you?*
- Other
   
   
If your service is provided in English do you need an interpreter/advocate? *
   
If you have a visual impairment do you require? *
   
Smoking
Do you smoke? If so, how many per day:
If you smoke, at what age did you start?
   
Ex-Smokers  
How old were you when you stopped?
How many did you smoke per day?
   
Alcohol  
How many units per week do you drink?
1 unit = half pint of beer, 1 glass of wine, or a pub measure of spirits
   
What Happens Next?
On receipt of your completed application, we will register you and you should come in for a health check with the nurse.
We will need you to come in with proof of identify and proof of address. We also need your signature if you have consented to organ donation. Please print out the relevant page and sign as marked and either post back to us or bring in. Without your signature we will not be able to apply your wishes.
Clicking the button below to submit your registration confirms your agreement to be registered with us.