WHMP Temporary Patient Registration Form

Fields marked "REQUIRED" are compulsory.. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 03/10/2022

Patient Details

TITLE *

SURNAME *

FIRST NAME *

MIDDLE NAME(S)

PREVIOUS NAME/SURNAME

DATE OF BIRTH *

BIRTH TOWN *

BIRTH COUNTRY *

NHS NUMBER

TEMPORARY ADDRESS *

TEMPORARY POSTCODE *

CURRENT ADDRESS *

CURRENT POSTCODE *

Contact Details

Please be aware we may leave a standard voicemail for you on the numbers provided. No private details will be disclosed in any messages left.

Clinicians may use SMS messaging to communicate with you regarding health issues, please indicate below whether you are happy to receive these messages.

MOBILE PHONE NUMBER (PLEASE PROVIDE HOME NUMBER IF NO MOBILE) *

HOME PHONE NUMBER

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

NAME OF CURRENT GP PRACTICE REGISTERED WITH

ADDRESS OF CURRENT GP PRACTICE REGISTERED WITH

Registering for the first time from Abroad?

FIRST DATE OF ENTRY TO THE UK

COUNTRY ARRIVING FROM

Registration Length

REGISTRATION LENGTH REQUIRED *

Less than 3 months

More than 3 months

Patient Disclaimer

The information provided above is correct to the best of my knowledge.

I have read and understood the information enclosed in the Patient Information Pack and have indicated my consent preferences throughout this form.

SIGNATURE *

Signature of patient

Signature on behalf of patient

SIGNED (PLEASE PRINT FULL NAME) *

DATE *

RELATIONSHIP TO PATIENT

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WHMP Temporary Patient Registration Form

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