Windmill Patient Registration Form (GMS1)

Last Updated: 19/08/2022

Patients Details

Title

Surname *

First name(s) *

Previous Surname

Birth Town *

Birth Country *

Date of Birth *

NHS number

Identity

Male

Female

Trans Woman (including male-to-female, transfeminine, etc)

Trans Man (including female-to-male, transmasculine, etc)

Non-Binary

Address *

Postcode *

Telephone *

Email *

I am a student at:

Children

Please complete this section if you are completing this on behalf of any children

Who has parental responsibility

Mother

Father

Grandparent

Foster Parent

Legal Guardian

Other

Do you have any children?

Yes No

If other was selected above, please provide details

Please Provide your children's name and date of birth so we can match your forms

Name and address of school

School contact number

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

Your previous address in UK

Name of previous GP while at previous address

Address of that Doctor

If you are from abroad

Your first UK address where registered with a GP

If previously resident in UK, date of leaving

Date you first came to live in UK

If you are returning from the armed forces

Address before enlisting

Service/Personnel No.

Enlistment date

Complete Registration

If you are registering a child under 5

I wish the child above to be registered with the named doctor for Child Health Surveillance

If you need your doctor to dispense medicines and appliances

I live more than 1 mile in a straight line from the nearest chemist

I would have serious difficulty in getting them from a chemist

Signature

Signature of patient

Signature on behalf of patient

Signed

Date

Please ensure you have completed the separate Health Questionnaire form

If you do not complete all the required forms we will not be able to register you as a patient. If you wish to sign up for online services, please complete the relevant form.

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Windmill Patient Registration Form (GMS1)

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