Fountain Medical Centre

New Patient Registration: Adult 18+ years old

FMC Register (GSM1): Adult 18+ years old
Title:
Sex: *
Address
Address
Postcode
City
Country
Would you like to receive SMS appointment reminders?

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

If you are from abroad:

Your first address where registered with a GP
Your first address where registered with a GP
Postcode
City
Country

If you are from the Armed Forces:

Address before enlisting
Address before enlisting
Postcode
City
Country

Electronic Prescribing

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

* Not all doctors are authorised to dispense medicines.

Next of Kin / Emergency Contact

Address:
Address:
Postcode
City
Country

Health Questionnaire

Do you live alone?
Are you a carer of anyone other than children?
Please list and date if possible any serious you have or have had in the past
Do you smoke?
Cigarettes, Cigars, pipes?
Do you smoke an E-cigarette
Do you drink Alcohol?
We measure alcohol in UNITs, a unit of alcohol is a half pint of beer or larger, a pub measure of wine or spirit.
Do you do any exercise?
Walking, Swimming etc..
To register with our practice this information is important to us, If you are not able to give this information please contact the surgery for registering.

Family History

Have your parents or siblings ever had any of the following

Maximum file size: 268.44MB