Application to Join the Surgery

Please complete the application form fully and return to the surgery reception

Highlight the form by scrolling over the form content and then right click print.

Group Practice

Application to join the practice

Please use separate application form if applying for more than one person

Please fill in all details requested

Today’s Date: _______________

First Name: _____________________ 

Surname: _________________

DOB: _______________

Gender ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­_______________

PPS Number: _______________

Nationality­­­­­­­­­­­­­­__________________________

Current Address:             ___________________________

                                         ___________________________

Telephone Number:         ___________________________

Do you have a current medical card?    YES     NO  

GMS number: ________________ 

Previous Address:            ___________________________

                                         ___________________________

Previous Doctor:              ___________________________

How long are you living in the area? __________________

Past Medical History: ____________________________________________

Current Medication:   ____________________________________________

Current Employment: ____________________________________________

CONSENT

I consent to receive notifications via SMS to include reminders, results and notifications. I am aware that I can withdraw my consent at any time by way of written notice. (Group Practice should be notified with any changes to contact information including address)

I have read a copy of the practice Privacy Notice, Data Processing Policy and have received a copy of the Practice Policies.

Signed Consent of Patient: _______________________