Family Doctor Services Registration - Nhs Form
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1
2Family doctor services registration
GMS1
Patient’s details
Please complete in BLOCK CAPITALS and tick
as appropriate
Surname
Mr
Mrs
Miss
Ms
Date of birth
First names
NHS
Previous surname/s
No.
Town and country
Male
Female
of birth
Home address
Postcode
Telephone number
Please help us trace your previous medical records by providing the following information
Your previous address in UK
Name of previous doctor while at that address
Address of previous doctor
If you are from abroad
Your first UK address where registered with a GP
If previously resident in UK,
Date you first came
date of leaving
to live in UK
If you are returning from the Armed Forces
Address before enlisting
Service or
Enlistment
Personnel number
date
If you are registering a child under 5
I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance
If you need your doctor to dispense medicines and appliances*
* Not all doctors are
authorised to
I live more than 1 mile in a straight line from the nearest chemist
dispense medicines
I would have serious difficulty in getting them from a chemist
Signature of Patient
Signature on behalf of patient
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
Any part of my body
Signature confirming my agreement to organ/tissue donation
Date ________/________/________
For more information, please ask at reception for an information leaflet or visit the website
, or call 0300 123 23 23.
NHS Blood Donor registration
I would 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
Signature confirming consent to inclusion on the NHS Blood Donor Register
Date ________/________/________
For more information, please ask for the leaflet on joining the NHS Blood Donor Register
My preferred address for donation is: (only if different from above, e.g. your place of work)
Postcode:
HA use only
Patient registered for
GMS
CHS
Dispensing
Rural Practice
042017_003
Product Code: GMS1
GMS1_072017_004 Family Doctor Services Registration_tearoff.indd 1
20/07/2017 14:27
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