Registration

STEP 1 of 4 : PATIENT DETAILS

Please fill in this form completely to register as a patient at Harcourt Medical Centre. If you do not know some of the details in the mandatory sections please type 'unknown'

To accompany your application we also require sight of photographic ID and proof of residency

ALL MANDATORY FIELDS ARE HIGHLIGHTED IN BLUE

Date of birth

NHS No.

Sex : Male | Female

Title

Surname

First names

Previous surname/s


Town and country of birth

Home address

Postcode

Telephone number


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

Your previous address in UK


Consent

Tick this box to confirm that you consent to the sharing of data here with any other organisations that may care for you.

Tick this box to confirm that you consent to the viewing of data by Harcourt Medical Centre that is recorded at other care services (e.g. Salisbury Walk-In Centre).

For transfers from other Salisbury GP surgeries we require an accompanying letter outlining your reasons for the change. Please tick this box to confirm you understand this.

Name of previous doctor while at that address

Address of previous doctor




Crane Bridge Road, Salisbury, Wiltshire, SP2 7TD | Tel: 01722 333214