Old Swan Health Centre Group Practice - New Patient Registration

Family doctor services registration

GMS1
Page 1 of 2

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	Surname
Other (please state)	First name(s)
Date of Birth	Previous surname(s)
NHS No.	Town & country of birth
Male Female
Home address
Postcode	Telephone 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 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*
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	*Not all doctors are authorised to dispense medicines
Signature of Patient Signature on behalf 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

Patient's details