Goodwood Court Medical Centre & The Eaton Centre
New Patient Registration Form
Thank you for asking to register at our medical
practice. Before we can consider your registration, we need to ask you
to complete this form as fully as possible. Incomplete forms may not be
accepted. PLEASE PRINT IT OUT and submit to us in person AFTER COMPLETION
To prevent fraudulent use of NHS resources, we must ask
you to provide the following original documentation when you register
and copies will be taken of these documents for record purposes. This
applies to ALL applicants
1: Photographic identification (Passport, or ID card
which has an up-to-date photograph) - or birth certificate
2: If from countries over than the EU: current Visa
or proof of eligibility to remain in the UK
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Your Family/Surname
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Your forename/given names |
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Your sex |
Male Female |
Your ethnic origin:
Your main language: |
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Your date of birth |
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Single |
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Your address in Brighton and Hove
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Postcode
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Note: only BN3 or parts of BN1 acceptable our
staff will advise you of our practice area limits |
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Your home landline |
01273 |
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Parent's mobile number |
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Your place of birth |
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Your NHS number
(not your NI number)
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Your previous address where you were registered
with an NHS GP |
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Your last GPs name and address |
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If you have just come from abroad in which
country were you living? |
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When did you come to the UK ?
How long are you staying in UK? |
PLEASE NOW SIGN TO APPLY FOR REGISTRATION WITH OUR
PRACTICE
Signed by parent:
Date:
_____________________________ ______________
Now we need to ask you some information about your
medical and personal history. All information on this form will remain
in your medical record which is kept confidential subject to "Caldicott
guidelines" more information is available on our notice board about
uses to which your medical records may be put. Information you write on
this form may be entered onto our computerised clinical database and
will be used primarily to ensure that you receive appropriate health
advice and that those accessing the medical record will be aware of
various aspects of your previous medical history.
