Fauldhouse Barclay – Registration Form
Residency Confirmation
Will be in the area for more than 3 months?
[632]
Personal Details
First registration in UK?
[636]
Gender at birth
[2363]
Current gender
[637]
Date of birth
[638]
Title
[2203]
Full legal name
[2204]
Middle names
[2229]
Other surnames
[642]
Mother’s maiden name
[2359]
Contact Info
Address
[643]
Postcode
[644]
Mobile
[647]
Landline
[646]
Email
[645]
Text permission
[2360]
CHI number
[648]
Place of birth
[650]
Country of birth
[651]
Previous GP
Last registered address
[657]
Previous GP name
[2213]
Previous GP address
[659]
Previous GP postcode
[2215]
Other Information
From outside UK?
[634]
Served in Armed Forces?
[635]
International Patients
Date arrived UK
[664]
Previous leave date
[665]
Recent country of residence
[666]
Interpreter needed
[2214]
Armed Forces History
Service number
[670]
Enlistment date
[671]
Left armed forces
[673]
Reservist?
[672]
First GP reg since leaving?
[674]
Pre-enlistment postcode
[2216]
Pre-enlistment address
[675]
Declaration
Signature
[694]
Declaration date
[695]
Representative name
[696]
Relationship to patient
[697]
