Form 1 - Gp Medical Registration Form - Gms1 - University Of Sheffield
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1
2Form 1 - Jun 2013
GP MEDICAL REGISTRATION FORM - GMS1
Office use
received &
validated by:
1. Have you ever registered with this practice before?
No
Yes
2. Sex:
Male
Female
3. Surname (family name):
4. First Name:
Middle name(s):
5. Previous surname: (if applicable)
6. NHS number:
7. Date of birth: day:
month:
year:
8. Age:
9. Marital Status:
Single
Married
Address in Sheffield
10. Room or flat number:
11. Name of flats or building:
12. House number and street name:
13. Postcode:
Town: Sheffield
County: South Yorkshire
14. Mobile telephone:
15. House telephone: 0114
UNITED KINGDOM ORIGIN - home address details before you came
INTERNATIONAL ORIGIN - details before you came to Sheffield
to Sheffield
16. Country of birth:
16. House number & street name:
17. Date of entry into the UK: dd
mm
yy
17. Town:
18. How many months will you stay in the UK?
18. POSTCODE:
If you have ever registered with an NHS doctor in the UK you must
answer questions 19 to 22
19. Town of birth:
19. Name & address of your most recent NHS doctor or medical
practice in the UK:
20. Name & address of your current NHS doctor or medical
practice:
20. The address you were living at when you were
registered with that doctor
21. If the address when you were registered with that
House number & street name:
doctor is different to the address at 16 above, write it here:
20a. Town:
21. Postcode:
22. If you have had any other address in the UK please add it
here:
22. If you have had any other address in the UK please add it
here:
23. Tick one to indicate your status:
Yes I am a student at the University of Sheffield, and my course title
Yes I am the partner or child of a registered student
/department is:
24. Ethnicity
Asian
Mixed
Black
Chinese
Other
White
Asian Indian
White & Black Caribbean
Black Caribbean
Chinese
Other ethnic Group
White British
Asian Pakistani
White & Black African
Black African
White Irish
Asian Bangladeshi
White & Asian
Black Other
Decline to say
White other
Asian Other
Other Mixed
25. First language:
English
26. Nationality:
UK National
Other - specify:
Other - specify:
27. YOUR SIGNATURE:
DATE: dd
mm
yy
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