Online GMS1 If you are new to the area and wish to register with the Practice please complete the form below – each person registering will need to complete a form. Personal DetailsTitleSelect one…MrMrsMissMsMxDrFull Name First Last Previous Surname Optional (If applicable)NHS Number (If unknown, please enter “NA”)Date of Birth Day Month Year GenderSelect one…MaleFemaleTransgenderTown and Country of Birth Current Address Street Address Address Line 2 City Postcode (include Postcode)First Spoken Language Mobile NumberHome Contact Number OptionalEmail Enter Email Confirm Email 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 Street Address Address Line 2 City Postcode Your Previous Address Street Address Optional Address Line 2 Optional City Optional ZIP / Postal Code Optional (This is usually the address when you were last registered with a GP)Your first UK address Street Address Address Line 2 City Postcode Date you first came to live in the UK Day Optional Month Optional Year Optional Do you have a preferred pharmacy? Yes No (You can find Pharmacies near you using the link below) Find Local PharmaciesName and Postcode of preferred pharmacy Address of preferred pharmacy Street Address Optional Address Line 2 Optional City Optional Postcode Optional 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 Street Address Address Line 2 City Postcode Service or Personnel Number Enlistment date Your EthnicitySelect one…White – BritishWhite – IrishWhite – TurkishWhite – GreekWhite – KurdishWhite – OtherAsian – IndianBritish IndianAsian – PakistaniBritish PakistaniAsian BangladeshiAsian – OtherBlack – CaribbeanBlack – AfricanBlack – OtherMixed – BritishMixed CaribbeanMixed – AfricanMixed – White & AsianMixed – OtherEthnic – ChineseEthnic – FilipinoEthnic – VietnameseEthic – OtherI do not wish to discloseIf "other" please specify the ethnic group you most identify with Main Spoken Language Optional (e.g. English)Next of Kin / Emergency Contact OptionalIf you are registering a child under 5 I wish the child above to be registered with the named doctor for Child Health Surveillance Optional If you need a doctor to dispense medicines and appliances I live more than 1 mile in a straight line from the nearest chemist Optional I would have serious difficulty in getting them from a chemist Optional (Tick all that apply)SignaturesWho's signing Patient’s signature Signature on behalf of patient Communication Consent I agree for the Practice to contact me using the details provided above. Optional Electronic Signature (Type your full name here) (Type your full name)By completing the section above, I hereby sign this form electronically.NHS Organ Donor RegistrationWould 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 (Check all that apply)NHS Blood Donor RegistrationWould you like to join the NHS Blood Donor Register? Yes No Already on it Have you given blood in the last 3 years? Yes No Do you have a preferred address for donation? Yes No Your preferred address for donation Street Address Address Line 2 City Postcode Summary Care RecordYour SCR is an electronic summary as key medical information taken from your GP medical records.If you need health care away from your usual Doctors Practice your enhanced SCR will provide those looking after you with key information to ensure you receive the best care at the right time.Do you consent to having a Summary Care Record? Yes No Do you consent to online services? Yes No Your Medical Information – Storing Your DataConsent Declaration I consent to my data being stored by the practice (Data Choices) Optional Name OptionalThis field is for validation purposes and should be left unchanged.