Falkland House Surgery

2a Falkland Road, Sheffield, S11 7PL

Telephone: 0114 266 0335

falkland.house@nhs.net

Sorry, we're currently closed. Please call NHS 111

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Pre-registration Form

Pre-registration Form

Family Doctor Service Registration

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Patient details

Title*

Date of Birth*

DD slash MM slash YYYY

Gender*

NHS Number

First Names*

Birth Town*

Surname*

Birth Country*

Ethnicity*

Current Address and Postcode*

Telephone*

Mobile*

Email Address*

Preferred Pharmacy and Location*

Please help us trace your previous medical records by providing the following information

Have you previously been registered with an NHS GP in UK?*

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No

Name of Previous GP*

Address of Previous GP*

Your Previous Address

This is usually the address when you were last registered with a GP

Your first UK address*

Date you first came to UK

DD slash MM slash YYYY

Are you returning from the Armed Forces?*

Yes

No

Please indicate if you have ever served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas*

Regular

Reservist

Family Member

Address and Postcode before enlisting*

Service or Personnel Number*

Enlistment date*

If you are registering a child under 5

Child Health Surveillance

I wish the child above to be registered with the named doctor for Child Health Surveillance

If you need a doctor to dispense medicines and appliances

Nearest Chemist

I live more than 1 mile in a straight line from the nearest chemist

Chemist Difficulty

I would have serious difficulty in getting them from a chemist

Signatures

Signatures*

Patient's signature

Signature on behalf of patient

Consent

I agree for the Practice to contact me using the details provided above.

Electronic Signature (Type your full name here)*

By completing the section above, I hereby sign this form electronically

NHS Organ Donor Registration

Would you like to join the NHS Organ Donor Register?*

Yes

No

Already on it

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death.*

Any of my organs and tissue

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

NHS Blood Donor Registration

Would you like to join the NHS Blood Donor Register?*

Yes

No

Already on it

Tick here if you have given blood in the last 3 years

I have given blood in the last 3 years

My preferred address for donation is:

Comments

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31810

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Telephone Opening Times

Monday
08:30am to 06:30pm
Tuesday
08:30am to 06:30pm
Wednesday
08:30am to 06:30pm
Thursday
08:30am to 06:30pm
Friday
08:30am to 06:30pm
Saturday
CLOSED
Sunday
CLOSED

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Comments

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12138

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Thinking about your recent visit, overall, how was your experience of our service?*

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Phone

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57092

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