NHS Family doctor services registration GMS1
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Old Swan Health Centre Group Practice, Crystal Close, Old Swan, Liverpool L13 2GA Tel: 0151 285 3737/3738

Patient's details

Mr Mrs Miss Ms
Other (please state)
First name(s)
Date of Birth
Home address
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 previously resident in UK, date of leaving
Date you first came to live in UK

If you are returning from the Armed Forces

Address before enlisting

Service or Personnel number

Enlistment date
If you need your doctor to dispense medicines and appliances*
*Not all doctors are
authorised to
dispense medicines
Signature of Patient Date

To be completed by the doctor
Doctor's name ............................................................................... HA Code .................................
I will dispense medicines/appliances to this patient subject to the Health Authority's approval
I am claiming rural practice payment for this patient. The distance in miles between my patient's home address and my main surgery is .............
I declare to the best of my belief this information is correct and I claim the appropriate payment as set out in the Statement of Fees and Allowance. An audit trail is available at the practice for inspection by the HA's authorised officers and auditors appointed by the Audit Commission.
Authorised Signature
Practice Stamp
Name Date