Fountain Medical Centre – OneContact Patient Portal

Title:

Mr

Miss

NHS Number:

Surname: *

First Names:

Prev Surname:

Date of Birth: *

Sex:

Male

Female

Ethnicity: *

First Spoken Language: *

Town and Country of Birth *

Address

Postcode

City

Country

Address

Telephone Number: *

Email Address:

Mobile Number:

Would you like to receive SMS reminders for your child’s appointments?

Yes

No

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

Your previous address in the UK

Postcode

City

Country

Your previous address in the UK

Name of doctor while at that address

Address of previous doctor

Postcode

City

Country

Address of previous doctor

If you are from abroad:

Your first address where registered with a GP

Postcode

City

Country

Your first address where registered with a GP

If previously resident in UK, date of leaving

Date you first came to live in the UK

Electronic Prescribing

Please nominate a pharmacy for electronic prescribing

If you need your doctor to dispense medicines and appliances * :

* Not all doctors are authorised to dispense medicines.

I live more than 1 mile in a straight line from the nearest chemist.

I would have serious difficulty in getting them from the chemist.

Next of Kin / Emergency Contact

Name:

Relationship:

Contact Number:

Address:

Postcode

City

Country

Address:

Name of child’s primary carer if not living with parent

Primary Carers contact number

Name of child’s School

I have filled in this form on behalf of

New Patient Registration: Child Under 5 years old

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

If you are from abroad:

Electronic Prescribing

If you need your doctor to dispense medicines and appliances * :

Next of Kin / Emergency Contact