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Register At Sir John Kirk Close Surgery

Online Registration

Please complete the below registration form by filling in as much information as possible. All questions marked * must be completed otherwise your registration cannot be processed.

If you are from outside of the UK remember to enter the full date that you first came to the UK.

Please note that it takes 48 hours to process a registration form. Only once the registration is complete will you be able to book an appointment to see the GP.

Patient's Details Please complete in BLOCK CAPITALS and tick as appropriate









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 are registering a child under 5
If you need your doctor to dispense medicines and appliances
     Date

 

 

 
NHS Organ Donor Registration
I want to register my details on the NHS Organ Donor Register as someone whose organs/tinnure may be used for transplantation after my death. Please tick the boxes that apply.

Signature confirming my agreement to organ/tissue donation     Date

 

For more information please ask at reception for an information leaflet or visit the website
www.uktransplant.org.uk or call 0300 123 23 23.

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

Signature confirming my agreement to organ/tissue donation     Date

 

For more information, please ask for the leaflet on joining the NHS Blood Donor Register
My preferred address for donation is: (only if different from above, e.g. your place of work)