Pre-registration form Patient's detailsPlease 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*MrMrsMissMsSurname*Date of birth* Date Format: DD slash MM slash YYYY First names*NHS Number*Previous surnamesGender*MaleFemaleTown and country of birth*Home address*Postcode*Telephone number*Please help us trace your previous medical records by providing the following informationYour previous address in UKName of previous GP practice while at that addressAddress of previous GP practiceIf you are from abroadYour first UK address where registered with a GPIf previously resident in UK, date of leavingDate you first came to live in UKWere you ever registered with an Armed Forces GPPlease 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 enlistingService or Personnel numberPostcodeEnlistment date Date Format: DD slash MM slash YYYY Discharge date (if applicable) Date Format: MM slash DD slash YYYY 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 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.Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision. Any of my organs and tissue or Kidneys Heart Liver Corneas Lungs Pancreas NHS Blood Donor registrationI 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.Post Title Post Excerpt Post CategoryUncategorizedPost Custom FieldPhoneThis field is for validation purposes and should be left unchanged.
