Which surgery are your registering for?
Choose Surgery Market Lavington Surgery Southbroom Surgery St James Surgery Lansdowne Surgery
*Which email you are emailing
Mr Mrs Miss Ms Other
Town and Country of birth
Please specify the ethnic group you consider you belong to:
White British White Irish Black Caribbean Black African Black Caribbean and White Black African and White Indian Pakistani Bangladeshi I do not wish to state Other ethnic group
Are they your next of kin?
Do you give us permission to discuss your medical records with them?
Do you have any allergies?
List allergies if you have any
Previous address in UK
Name and address of previous GP
If you are from abroad
Date you came to live in the UK:
If you are returning from abroad
If you are returning from the armed forces
Address prior to enlisting
I am not ordinarily a resident in the UK
European Economic Area (EEA) Country
For a list of EEA countries visit: www.gov.uk/eu-eea
Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?
Do you have a carer?
Are you a carer for someone
Permission to discuss medical information with your carer
Current smoker Ex smoker Never smoked
Do you wish to stop smoking
Yes No Non-applicable
*We offer a smoking cessation service please ask for information
How often do you have a drink?
Never Monthly Weekly Daily
How many drinks do you consume?
Good Partly sighted Registered blind
Good Partly deaf Registered deaf
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