New Patient Registration Form

Please complete this online registration form. The information will allow the surgery to complete the government required Family Doctor Services Registration Form (GMS1) on your behalf.

Last Updated: 04/08/2020

Your Contact Details


















Information About You








Previous GP


Medical Information






Choice of pharmacy


Carers







NHS Organ and Blood Donor Registration, Individual Health Record and Living Wills

To become an organ donor in Wales you can register a decision on the NHS Organ Donor Register by ticking the relevant boxes below, or choose to do nothing. By doing nothing you will be considered as having no objection to organ donation and your consent may be deemed to be given. If you do not want to become an organ donor you can register this decision on the Organ Donor Register. You can do this by going to the website or calling the phone number below. It is not possible to offer the facility to opt out via this form at the present time. www.organdonationwales.org or call 0300 123 23 23






Smoking



Alcohol






Family History


Next of Kin


Contacting You


Signature and consent

I declare to the best of my belief this information is correct. By electronically signing below I am consenting to: the choices made in the NHS organ donor register section; the NHS blood donor register if you have selected that preference; and to the Family Doctor Services Registration Form (GMS1) being completed and signed on my behalf by the surgery.