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Online Pre-Registration

Poole Town Surgery Registration Form

"*" indicates required fields

Patient details

Title*

Date of Birth*

DD slash MM slash YYYY

Gender*

NHS Number

First Names*

Birth Town*

Surname*

Birth Country*

Current Address and Postcode*

Street Address Address Line 2 City Postcode Country

Phone Number*

Email Address*

Please help us trace your previous medical records by providing the following information

Have you previously been registered with an NHS GP in UK?*

Yes

No

Name of Previous GP*

Address of Previous GP*

Your Previous Address

This is usually the address when you were last registered with a GP

Your first UK address*

Date you first came to UK

DD slash MM slash YYYY

Are you returning from the Armed Forces?*

Yes

No

Please indicate if you have ever served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas*

Regular

Reservist

Family Member

Address and Postcode before enlisting*

Service or Personnel Number*

Enlistment date*

If you are registering a child under 5

Child Health Surveillance

I wish the child above to be registered with the named doctor for Child Health Surveillance

Signatures

Signatures*

Patient's signature

Signature on behalf of patient

Consent

I agree for the Practice to contact me using the details provided above.

Electronic Signature (Type your full name here)*

By completing the section above, I hereby sign this form electronically

NHS Organ Donor Registration

Would you like to join the NHS Organ Donor Register?*

Yes

No

Already on it

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.*

Any of my organs and tissue

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

Photo ID

Max. file size: 128 MB.

Proof of Address

Max. file size: 128 MB.

Consent*

I agree to the privacy policy.

Phone

This field is for validation purposes and should be left unchanged.

67458

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Date of Birth*

Address*

Phone*

Email*

Smoking Status*

How many per day?*

Consent*

I agree to the privacy policy.

Email

This field is for validation purposes and should be left unchanged.

41670

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