Pemberton Surgery

01942 367199

Pre Registration Form

  • Patient's details

  • Date Format: DD slash MM slash YYYY
  • Please help us trace your previous medical records by providing the following information


  • If you are from abroad


  • Were you ever registered with an Armed Forces GP

  • Date Format: DD slash MM slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.
    *Not all doctors are authorised to dispense medicines
    I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.
  • All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.