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Poole Town Surgery

Poole Town Surgery

If you wish to register you will need to complete a registration form. We will send you a message once you are registered.

Please see boundary map below for details of the areas we cover (use the ‘postcode’ facility on this map to see if you are within our boundary)

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.

6981

Do I need ID or proof of address?

No, you do not need ID, an NHS number or proof of address to register.

Ideally we would like this supporting documentation as it can:

help the surgery find your medical records or transfer them from your current GP
confirm that you live in the surgery’s area (or “practice boundary”) if they do not accept patients from outside this area

If you do not have a permanent address you can still register using a temporary address or the address of the GP surgery.

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Date of Birth*

Address*

Phone*

Email*

Smoking Status*

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Consent*

I agree to the privacy policy.

Comments

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

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