Registration Form – Victoria Medical Centre

Online form

Fields marked * are required. This form is processed by the practice's website form plugin; in this static preview it is display-only.

Title

Surname

Previous surname/s

First Name

Date of birth

NHS No.

Gender

Town of Birth

Country of Birth

Home address

Postcode

Telephone number

E-mail Address

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

Your previous address in UK

Name of previous doctor while at that address

Address of previous doctor

If you are from abroad

Your first UK address where registered with a GP

Date of leaving (If previously resident in UK)

Date you first came to live in UK

If you are returning from the Armed Forces

Address before enlisting

Service or Personnel number

Enlistment date

If you are registering a child under 5 I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance

If you need your doctor to dispense medicines and appliances*

*Not all doctors are authorised to dispense medicines

NHS Organ Donor registration

I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death. Please tick as appropriate Kidneys Heart Liver Corneas Lungs Pancreas Any part of my body I do not want to join the NHS Organ Donor Register

Confirm your consent to organ donation Confirm your consent to organ donation

NHS Blood Donor registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be pre p a red to donate blood Check this if you have given blood in the last 3 years

For more information, please ask for the leaflet on joining the NHS Blood Donor

Postcode

Online form

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