Pre-registration form

Patient's details

Please be aware, due to the current situation with COVID -19, if you are living out of the practice catchment area or if you are already registered with another practice in the area, we are unable to register you with Lucie Wedgwood Surgery.

Title*

Mr
Mrs
Miss
Ms

Surname*

Date of birth*

First names*

NHS Number*

Previous surnames

Gender*

Male
Female

Town and country 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 GP practice while at that address

Address of previous GP practice

If you are from abroad

Your first UK address where registered with a GP

If previously resident in UK, date of leaving

Date you first came to live in UK

Were you ever registered with an Armed Forces GP

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

Regular
Reservist
Veteran
Family Member (Spouse, Civil Partner, Service Child)

Address before enlisting

Service or Personnel number

Postcode

Enlistment date

Discharge date (if applicable)

Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

If you need your doctor to dispense medicines and appliances*

*Not all doctors are authorised to dispense medicines

I live more than 1.6km in a straight line from the nearest chemist
I would have serious difficulty in getting them from a chemist

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.

Yes I would like to join the NHS Blood Donor Register
Tick here if you have given blood in the last 3 years

My preferred address for donation is: (only if different from above, e.g. your place of work)

All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.

You MUST also complete the online health questionnaire and zero tolerance form*

Before we can register you as a patient you MUST complete the online health questionnaire and zero tolerance form. Please confirm that you understand this and that you have already or will immediately complete the health questionnaire form the zero tolerance form

Yes I understand and I have or will complete both forms

Consent*

Please note that no medical information or questions will be responded to. The data you supply on this form will be stored on our website, which is hosted by a third party, until it has been processed by the practice. The data will be used lawfully, in accordance with the Data Protection Act 2018, which gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly. The practice privacy policy can be viewed on this website.

I agree to the privacy policy.

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

Patient's details

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

If you are from abroad

Were you ever registered with an Armed Forces GP

Helpful links

Further Info