TOWN GATE PRACTICE REGISTRATION FORM

 Mr		Mrs		Ms	 	Other please state _______________

Surname___________________________

Forenames__________________________

Previous Surname____________________

Male	Female			Date of Birth _______________

Town & Country of Birth__________________________________________

Home Address___________________________________________________

Postcode________________________________________________________

Telephone Numbers: 			Home_________________________
					Mobile________________________

Your Nationality/Ethnic Origin:__________________________________		

Proof of I.D and Address required in the form of Photo ID or other documentation I.E. Passport, Driving Licence, Bank Statement, Solicitor letter or Utility Bill.

Previous Address in UK__________________________________________

______________________________________________________________

Name & Address of Previous Doctor_________________________________

_______________________________________________________________

If you are coming from abroad the first UK address where you have been registered with a GP

NHS Number (if known) _________________________________________________

Signature__________________________________________      Date_________________

Do You Have Any Allergies? _______

Please State Allergies_________________________________________________________  P.T.O

TOWN GATE PRACTICE REGISTRATON FORM 			Part 2

Please tell us about yourself

What is your Height		__________

What is your Weight		__________

Do you smoke? (please delete as 			Never smoked 
appropriate)						Given Up         
							Smoker            

Do you drink alcohol?					Yes		
                                                                                     No		

If yes, approximately how many units a week?
(1 unit = ½ pint of beer, 1 small glass of wine or 1 pub measure of spirits)

Do you take regular exercise?				Yes 
							 No 

Any significant illnesses or operations?		Yes
                                                                                    No 

Please list with approximate dates

Do you take regular medication?			Yes 
                                                                                    No  

Ladies – when was your last smear test?  _______________

Children Age 5 & under
Are all immunisations up too date 			Yes
                                                                                    No 

1st baby immunisation – 5 in 1		Approx dates__________
2nd baby immunisation – 5. in 1		_____________________
3rd baby immunisation – 5 in 1		_____________________
Men C						_____________________
MMR						_____________________
Pre-school booster				_____________________