Glebe Park Surgery

01522 530633

Pre registration form

  • Patient's details

  • DD slash MM slash YYYY

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

  • If you are from abroad

  • Were you ever registered with an Armed Forces GP

  • DD slash MM slash YYYY
  • MM slash DD slash YYYY
  • Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.
    *Not all doctors are authorised to dispense medicines
    Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision.
    I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.
  • All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.