Pre-registration Form

Step 1 of 2

Title
Date of Birth
Sex:
Address
Email Address

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

Previous Address
Address of previous doctor
Are you from abroad?
Are you in the Armed Forces?

If registering a child under 5:

If you need your doctor to dispense medicines and appliances:

Not all doctors are authorised to dispense medicines.

NHS Organ Donor registration:

Please tick as appropriate:
Or only my:

NHS Blood Donor registration

Emergency Contact

Address