Sturry Surgery & Canterbury Health Centre

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Downloads

GP Registration
for Canterbury Christ Church
Students

Use this form to register on-line. Please complete all fields (* are mandatory) and then click the Submit button to send the form to us.

*Title:
Other Title
*Surname:
Previous Surname:
*First Name:
*Date of Birth: DD-MM-YYYY
*Male/Female:
NHS Number: _ _ _ /_ _ _ /_ _ _ _
*Town & Country of Birth:
*Current Address (term time):
*Postcode:
*Tel Number:
*University Email Address:	@canterbury.ac.uk
*Preferred Surgery to attend:
*Previous Address:
*Name of Previous Doctor:
*Address of Previous Doctor:
*Are you from abroad:
*First UK Address where registered with a GP:
*If previously resident in the UK, date of leaving:
*Date you first came to live in the UK:
*Are you returning from the armed forces:
*Address before enlisting:
*Service or Personnel Number:
*Enlistment Date:

NHSOrgan Donor registration I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death. Please tick as appropriate
Kidneys Heart Liver Corneas Lungs Pancreas Any part of my body
For more information, please ask for the leaflet on joining the NHS Organ Donor Register
NHSBlood 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
Tick here to join the NHS Blood Donor Register

Tick here if you have given blood in the last 3 years
For more information, please ask for the leaflet on joining the NHS Blood Donor Register

Summary Care Records
Summary Care Records have been introduced in this practice. A Summary Care Record is an electronic record containing a summary of your Medications, Allergies and Adverse Reactions, which can be made available to NHS healthcare staff caring for you in an emergency or when your GP practice is closed. If you would like a Summary Care Record you need take no further action, one will be created for you. If you do not want a Summary Care Record you must complete an Opt Out form and return it to the surgery. Opt Out forms are available from Reception. If you would like more information – ask for a leaflet at reception which provides more information to help you decide. You can also phone the Summary Care Record Information Line on 0300 123 3020 or visit the website www.easternandcoastalkent.nhs.uk/scr * I have read the above information and understand that it is my responsibility to notify the surgery if I do not want a Summary Care Record

* I have filled in this form on my own behalf

Items marked * must be completed Please allow two working days for this request to be processed

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