New Patient Registration

If you would like to register with the practice please use this form.

To ensure that you fall within our boundary, please check our practice boundary with your postcode, before filling out the registration form.

To find out your NHS number, please visit www.england.nhs.uk/my-nhs-number/

New Patient Registration

If you are human, leave this field blank.

Patient's Details

Title *

Mr

Mrs

Miss

Ms

Other

Please specify:

First Name(s) *

Surname: *

Previous Name (if applicable):

NHS Number: *

Please see start of form for a link to help you find this

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Gender *

Male

Female

Indeterminate

Unspecified/Unknown

Home Address: *

Postcode: *

Will you be at this address for longer than 3 months: *

Yes

No

Town and Country of birth: *

Previous address in UK:

Please include postcode.

Name and Address of Previous Surgery:

Please include postcode.

Have you been registered at either of the following practice previously?

Marlborough Medical Practice

Pewsey Surgery

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

Email Address: *

Can we contact you by text?

Yes

No

Can we contact you by email?

Yes

No

Emergency Contact

Full Name:

Relationship to you:

Phone Number:

Are they your Next of Kin?

Yes

No

Do you give us permission to discuss your medical records with them?

Yes

No

Ethnicity

Please specify the ethnic group you consider you belong to: *

White British

White Irish

Other White

Black Caribbean

Black African

Other Black

Black Caribbean and White

Black African and White

Other Mixed

Indian

Pakistani

Bangladeshi

Other Asian

I do not wish to state

Other ethnic group

Please state: *

Do you speak English?

Yes

No

Do you read English?

Yes

No

First Language:

Allergies

Do you have any allergies?

Yes

No

Please specify what you are allergic to, what happens and when you had your first reaction:

If you are from abroad

Registering for the first time in the UK

Date you came to live in the UK:

Please use this date format: DD/MM/YYYY.

If you are returning from abroad

Previously been a resident in the UK

Date you left the UK:

Please use this date format: DD/MM/YYYY.

Date you returned to the UK:

Please use this date format: DD/MM/YYYY.

Electronic Prescription Service (EPS)

Do you currently use the Electronic Prescriptions Service?

Yes

No

Would like to nominate a new pharmacy, please provide the name and location:

We are able to dispense your prescriptions if you live more than one mile from a pharmacy. Are you interested in this service?

Yes

No

Carers

Do you have a carer?

Yes

No

Are you a carer for someone?

Yes

No

Name of carer:

Phone Number:

Address:

Do you give us permission to discuss your medical record with your carer?

Yes

No

Please complete this section if you have served in the British Armed Forces

Service Number:

Enlistment Date:

Please use this date format: DD/MM/YYYY.

Leaving Date:

Please use this date format: DD/MM/YYYY.

FMed133 Form Enclosed?

Yes

No

Is this your first registration with a GP since leaving the Armed Forces?

Yes

No

If yes, please provide your address before enlisting

Please include postcode