Please fill in all the boxes and submit the form. Use a separate form for each member of the family. The information is required to register with the health authority that you have changed your doctor and to retrieve your medical records from your previous GP. This information is used solely for the purpose of delivering health care.

This information is not via a secure server so if you would prefer to print out a form and send it, then address it to Sue Irwin at the surgery address.

Although you can see any of the three doctors of your choice your registration will be under Dr Masharani. On receipt of the application, we will send you a patient information pack. Some time later you will receive a new set of NHS medical cards which you will need to keep in a safe place. Your registration with the practice occurs as soon as we receive the registration details from you.

Areas marked with * are mandatory fields

Title* MR MRS MISS DR

First Name(s)*  Surname*

Previous surname(s)          

Town and country of birth* 

Date of birth(dd/mm/yy)*

NHS number ( this is on your NHS card and is not the same as a national insurance number. Leave blank if you don't know what it is)                 

Address*:

House Name/ Number

Street/ Road

Town/ Village

Post Code

Home telephone number* 

Mobile telephone number

Email address

If you wish to be contacted by email tick this box

The following details will help us trace you previous records:

Your previous address in the UK:*

House Name/ Number

Street/Road

Town/Village

Post Code

Name of your previous doctor in the UK*

Address of previous doctor:

Practice Name

Street/Road

Town/Village

Post Code

If you are from abroad, or returning from abroad:

Your first UK address where registered with a GP:

House Name/ Number

Street/Road

Town/Village

Post Code

If previously resident in the UK, date of leaving

Date you first came to live in the UK

If you are returning from the Armed forces:

Address before enlisting:

House Name/ Number

Street/Road

Town/Village

Post Code

Service Personnel number

Enlistment date

NHS Organ donation scheme

If you would like the NHS organ donation register as someone whose organs may be used for transplantation after death please any of the boxes below (if you don't mind any part then tick only the first box otherwise tick one or more to specify):

Any part    Cornea    Heart    Kidneys    Liver    Lungs    Pancreas