Dr Jefferies and Partners

NHS Family Doctor Services Registration - GMS1

Patient's Details

Boxes with * are mandatory fields

Miss Mrs Ms Mr Other*

Date of birth*

Your NHS number

Female Male Other*

Surname*

First names*

Please complete to make payment

Previous surname/s

Town and country of birth*

Current postcode*

Current address*

UK Phone number*

Please tick if this form is for a child under 18 years old

If the child has a guardian who is also registered with us, please enter the details below

Guardian's Full Name*

Guardian's Date of birth*

Guardian's Postcode*

Please tick if you have been registered with a UK GP before

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

Previous address in UK*

Postcode*

Name of previous GP practice while at that address*

Please tick if you are from abroad and this is your first NHS registration

If you are from abroad, please provide the following information:

Your first UK address where registered with a GP*

Postcode*

Date of entry into the UK*

Please tick if you have ever registered with an Armed Forces GP

If you were registered with an Armed Forces GP, please provide the following information:

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas

Regular Reservist Veteran Family Member (Spouse, Partner, Child)

Address before enlisting

Postcode

Service or Personnel number

Enlistment date

Discharge date (if applicable)

Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

Please tick if you would you like to register for NHS Organ or Blood Donation

NHS Organ Donation Registration, please provide the following information:

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. Please tick the boxes that apply:

Kidneys Heart Liver Corneas Lungs Pancreas Any of my organs and tissue

Type your name below to join the register* Today's date*

Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision.

NHS Blood Donor Registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

Tick if you gave blood in the last 3 years

My preferred address for donation is:

Type your name below to join the register* Today's date*

All blood types are needed, especially O and B negative. Visit www.blood.co.uk or call 0300 123 23 23.

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NHS Family Doctor Services Registration - GMS1

Patient's Details

If the child has a guardian who is also registered with us, please enter the details below

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

If you are from abroad, please provide the following information:

If you were registered with an Armed Forces GP, please provide the following information:

NHS Organ Donation Registration, please provide the following information:

NHS Blood Donor Registration

Latest Messages

Register Online In Five Minutes

NHS Family Doctor Services Registration - GMS1

Patient's Details

If the child has a guardian who is also registered with us, please enter the details below

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

If you are from abroad, please provide the following information:

If you were registered with an Armed Forces GP, please provide the following information:

NHS Organ Donation Registration, please provide the following information:

NHS Blood Donor Registration

Practice Choice

Pharmacy

GDPR