GMS1 form

Patient’s Details

Title

Mr

Mrs

Miss

Ms

Surname:

Date of Birth:

Please use this date format: DD/MM/YYYY.

First Name(s)

NHS Number:

Previous Surnames:

Gender

Male

Female

Indeterminate

Town and Country of birth:

Home Address:

Postcode:

Phone Number:

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

Your previous address in UK:

Name of previous doctor while at that address:

Address of previous doctor:

If you are from abroad

Your first UK address where registered with a GP:

If previous resident in UK, date of leaving:

Please use this date format: DD/MM/YYYY.

Date you first came to live in UK:

Please use this date format: DD/MM/YYYY.

If you are returning from the armed forces

Address before enlisting:

Service or personnel number:

Enlistment date:

Please use this date format: DD/MM/YYYY.

If you need your doctor to dispense medicines and appliances

Not all doctors are authorised to dispence medicines

Dispensing:

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

NHS Organ Donor registration

For more information, please ask for the leaflet on joining the NHS Organ Donor Register

The NHS Organ Donor Registration keeps a record of people’s details and donation choices. If you would like to join the NHS Organ Donation Register please visit their website on: www.organdonation.nhs.uk/consent.do

NHS Blood Donor registration

For more information, please ask for the leaflet on joining the NHS Blood Donor Register

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

Tick here if you have given blood in the last 3 years

Signature confirming consent to inclusion on the NHS Blood Donor Register

Checkboxes

Signature

Signature on behalf of Patient

Date:

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Patient’s Details

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

If you are from abroad

If you are returning from the armed forces

If you need your doctor to dispense medicines and appliances

NHS Organ Donor registration

NHS Blood Donor registration