New Patient Registration Form

Register (GSM1)

If you are new to the central Halifax (West Yorkshire) area and wish to register with the practice, please complete the form below – each person registering will need to complete a separate form.

Please check your address is within our practice catchment area before submitting this form.

If you require a Temporary Registration only, please note we are happy to see and treat anyone who is in the area for a short time – please contact us about completing a Temporary Registration form at the surgery.

Title: *
Gender: *
Address: *
Address:
Postcode
City
Country

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

Your previous address in the UK:
Your previous address in the UK:
Postcode
City
Country
Address of previous doctor:
Address of previous doctor:
Postcode
City
Country
Have you lived in the UK since birth?

If you are from abroad:

Your first UK address where registered with a GP: *
Your first UK address where registered with a GP:
Postcode
City
Country
Are you returning from the Armed Forces?

If you are returning from the Armed Forces:

Please provide your address before enlisting:
Please provide your address before enlisting:
Postcode
City
Country

If registering a child under 5:

If you need your doctor to dispense medicines and appliances:

NB. Not all doctors are authorised to dispense medicines.

NHS Organ Donor Registration:

I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death.

Please tick as appropriate:
Or only my:

NHS Blood Donor Registration