Temporary Patient Registration Form

Is this your first registration with a GP Practice in the UK?

Yes

Will you be in the area for more than 3 months?

Yes

STOP

If you will be in the area for more than 3 months, please complete a New Patient Registration Form.

You can complete the New Patient Registration Form here.

Name(Required)

Prefix Forenames Surname

Previous surname (if required)

Date of birth(Required)

Sex(Required)

Female

Male

This field relates to gender assigned at birth.

Email(Required)

The data supplied in this field will not be input to, or updated in, the Community Health Index (CHI), but will be held on the GP Practice’s system.

Home phone(Required)

The data supplied in this field will not be input to, or updated in, the Community Health Index (CHI), but will be held on the GP Practice’s system.

Mobile phone(Required)

The data supplied in this field will not be input to, or updated in, the Community Health Index (CHI), but will be held on the GP Practice’s system.

Your temporary address(Required)

Street Address Address Line 2 City County Post code

Your home address(Required)

Street Address Address Line 2 City County Post code

Name and address of your GP Practice(Required)

Street Address Address Line 2 City County Post code

Duration of stay(Required)

15 or more days

Less than 15 days

Thank you for completing the form. After you click submit this will be sent to the surgery and we will register you. If there are any gaps in your information we will let you know.