Before completing the form please check with the below link if you are in our catchment area. 

Check to see I am in Swineshead Medical Centres catchment area 

PART A

Try to provide as much information as possible. If a question does not apply to you or the person you are registering write ‘Not applicable’ or ‘N/A

Section 1 (PART A)

Who is registering? 

Are you registering? Required

Only provide your details if you are registering someone else.

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Section 2 - Details of patient registering

Required
Required
Required
Current address Required
What is your sex as recorded on your NHS record? Required
Date of birth Required
Required
Have you just left the military? Are we the first GP practice you are registering with since leaving the military? Required

If you were given a FMED133A form (sometimes called an FMED1 form) when you left the UK Armed forces, you should give this to your GP surgery

Have you just moved to the UK? Required
If yes, what date did you arrive in the UK?
Required
If you have recently moved, what was your previous address?
Are you retired? Required
Required
What is your martial status? Required
Ethnicity Required
Do you need an interpreter for your appointments? Required
Required
Are you a carer? Required
What type of carer are you?
Do you have a carer Required
Required
Have you ever served in the UK Armed Forces or were you ever registered with a Ministry of Defence GP in the UK or overseas? Required
Discharge reason
Active service?

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What best describes you? Required
If you have stopped, what was your stop date?
How often do you drink alcohol? Required
Required
How often have you had six or more units of alcohol on a single occasion in the last year? Required
Required

If your local pharmacy is over 1 mile from where you live (as the crow flies) you can collect your medication from the GP surgery dispensary

Required

Do you want important information from your GP record to be available to other health and care professionals?

Your GP surgery needs permission to share important information from your GP record. This is called a Summary Care Record (SCR). Your SCR can only be shared with health and care staff across England who are providing you with direct care. It gives them access to vital information from your GP record. Please note none of your data is sold 

1. Yes, share a Summary Care Record with additional information Includes details of your medicines, allergies, adverse reactions and additional information, which includes details of any significant illnesses and health problems, operations and vaccinations

2. Yes, share a Summary Care Record without additional information Includes details of your medicines, allergies and adverse reactions only

3. No, do not share a Summary Care Record Details of your medicines, allergies, adverse reactions and any additional information will not be shared with anyone involved in your direct care

Select your answer Required
Do you consent to sharing of your medical information with other healthcare providers when necessary for your treatment? (example: ambulance service, district nurses etc) Required
How would you like us to send information to you? Required
Required
Required

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Section 3 - Patients under 18 years

For children under 12 months only 

For new born babies please bring in birth certificate and the red book.  

Where were they born?

For patients under 18 years

Have you had all your routine vaccines?
Did you get your routine vaccinations in the UK?

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Section 4 - Additional information

Please tick one box that best describes your ethnic group or background from the options below:

Part B

Have you ever had any of these conditions?
Required
Required
Required