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Patient Name
If registering a child, please provide the parent or guardian's phone number.
Patient Email Address
If registering a child, please provide the parent or guardian's email address.
Has this patient previously been known by another name?

Residency

Patient's Current Address
Is the patient ordinarily resident in the UK?
Can the patient access a local chemist or pharmacy to collect medication?
Patient's Previous Address

Previous GP Details

Previous GP Surgery Address
Clear Signature
Please sign to confirm the information provided for registration.

Donor Information

The questions in this section are optional.
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The GP Surgery Registration form template helps patients register for a doctor online efficiently. By adding this form template to your website, you can collect necessary patient details, and help you provide personalized care.

Using the GP Surgery Registration Form Template

The form provides structured fields to record essential patient details. Let’s break down these fields.

  • Patient Details: The form records the patient’s full name, phone number, email address, and gender. If the patient is a child, the form asks for their guardian or parent’s phone and email. Moreover, patients can specify their previously known names, if any.
  • Residency: Here, patients can input their full current and previous addresses. Also, the form lets patients specify whether they can access a local chemist or pharmacy to collect medication.
  • Previous GP Details: In this section, patients can share their previous GP surgery’s name and the address where the surgery took place in case they have any prior surgeries. This data helps in understanding the patient’s medical condition.
  • Ministry of Defence Details: The form asks whether the patient has been registered with a Ministry of Defence GP. They can specify their position in the Armed Forces from options like regular, veteran, or family member.
  • Signature: In this field, the patient can provide an e-signature confirming the authentication of their details.
  • Donor Information: In the end, the form provides checkboxes to patients to specify whether they want to join the NHS organ and blood donor register. If they tick the checkbox, an e-signature field will appear to confirm their choice.

You can customize the GP Surgery Registration form template according to your needs with our powerful drag-and-drop form builder.

So, what are you waiting for? Sign up with WPForms to access the GP Surgery Registration form template to register new patients easily.