New Patient Registration Form

All Sections MUST BE completed to enable your prompt registration to the Practice as a patient
* You will need Photo ID at your first appointment

Sex:

Male

Female

OtherOther

Surname:

First Names:

Title:

MR/MRS/MISS/MS/MASTER/OTHER

Date of Birth:

Address:

Post Code:

Tel No: (Home)

Work:

Mobile:

Email:

Occupation:

Employer:

Work Address:

Immunisations in the last 12 months

(For female patients over 21)

Insurance Status:

(eg BUPA, Foresters, Oddfellows, PPP, WPA etc)

Insurance Scheme Number:

GY Health Benefit Number:

Next of Kin:

Address:

Post Code:

Relationship:

Telephone Numbers Home:

Work:

Mobile:

If you have moved to Guernsey in the last 5 years please state:

Date of Arrival:

Intended Length of Stay:

Previous Address:

Post Code:

With which surgery would you like to be registered With which surgery would you like to be registered

With Which Doctor Would You Like To Be Registered?

Previous Doctor:

Previous Doctor Address:

Post Code:

Telephone Number:

Have you any known allergies (eg medicines, stings, animals etc)?

If Yes Please Give Details.

Are you on any medication at the moment?

If Yes Please Give Details.

Have you had any past serious illness or operations?

If Yes Please Give Details.

Have you ever worked in the Armed Forces?

If Yes Please Give Details.

I understand that the Practice has the right to accept or decline this application.

I understand.

I agree to pay for all treatment given by the Practice at the time of treatment. Failure to do so may result in recovery of outstanding debt being passed on to a third party for recovery of the debt on the Practice's behalf. No medical information would be passed over to the third party recovery agent.

I agree.

I agree that the Practice may disclose personal details and details of medical records regarding both myself and my dependants to all those involved in providing me/them with healthcare and related services both inside and outside the Practice.

I agree.

I give my permission to the Practice to request information from my previous doctor and I agree to meet reasonable charges relating thereto.

I give my permission.

Please see Island Health's Privacy Notice in relation to any of your data we may hold.

If you are human, leave this field blank.

UPON COMPLETION, PLEASE PROVIDE FORMAL PHOTO ID TO EITHER OF THE SURGERIES BELOW

L’Aumone Surgery tel: 256517 | St Sampson’s Medical Centre tel: 245915 | Town Surgery, 1 Le Truchot tel: 724747