Adult Registration Form

Required Information
Are you looking after someone at home?*
- Yes
- No
If so, please tell us who you look after.
Please tell us if you are looking after someone who is ill, frail, disabled, has mental health/emotional support needs or substance misuse problems
What is your relationship?
Do you have a carer?*
- Yes
- No
If yes, please provide your carers name and contact number

Smoking
Do you smoke?*
- Yes
- No
- Ex smoker
If you are a current smoker, how many on average do you smoke a day?
Please help us trace your previous medical records by providing the following information
What was your previous address in the UK?*
Postcode*
Name and address of your previous GP while at that address?*
Postcode*
If you are from abroad
Are you from abroad?*
- Yes
- No
Your first UK address where Registered with a GP*
Postcode*
If previously resident in UK date of leaving*
Day
Month
Year
Date you first came to the UK*
Day
Month
Year
Please complete Appendix 1 found at the end of this form.
If you need your doctor to dispense medicines and appliances
For dispensing practices only
- I live more than 1 mile in a straight line from the nearest chemist
- I do not live more than 1 mile in a straight line from the nearest chemist
Patient Declaration for all patients who are not ordinarily resident in the UK
Please see Supplementary questions at the end of the form for patient declaration.
Are you ordinarily resident in the UK*
- Yes
- No

NHS Organ Donor registration
From May 2020 Organ donation in England has changed to an 'opt out' system. You may also hear it referred to as 'Max and Keira's Law'.
This means that if you are not in an excluded group, and have not confirmed whether you want to be an organ donor - either by recording a decision on the NHS Organ Donor Register, or by speaking to friends and family – it will be considered that you agree to donate your organs when you die.
You still have a choice about whether or not you wish to become a donor and your faith, beliefs and culture will continue to be respected. Get the facts about organ donation to help you decide.
NHS Blood Donor registration
Consent to join the NHS Blood Donor Register
I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

Signature to confirm consent to inclusion on the NHS Blood Donor Register at the bottom of this form.

For more information, please ask for the leaflet on joining the NHS Blood Donor Register
I have given blood in the last 3 years
Yes
My preferred address for donation is (only if different from above eg your place of work)

Personal Details