Register Online To register with our practice please complete this form as fully as possible. All fields marked * are mandatory and must be completed. If you need any assistance completing the form please contact the practice. New Patient Registration Fields marked with an asterisk are compulsory*. Will you be in the area for more than 3 months? Yes No Online registration is not available for temporary residents Sorry, if you are in the area for less than 3 months we cannot register you via our online form. Please contact the surgery for further information. Personal Details Have you registered with this practice before * Yes No Are you a student? * Yes No Gender Male Female Is this your first registration with a GP Practice in the UK? Yes No Date of birth * Date of birth DD Date of Birth MM Date of Birth YYYY Age * Title Forenames Surname (Family Name) Previous Surname Address Please include any flat, floor and block number or name in your address details. Postcode Postcode Email Address Enter Email Confirm Email Address Confirm Email Home Phone Number Your UK Mobile Number We require your UK mobile number to contact you with any questions. We cannot dial any number outside UK. If you do not have a UK mobile number please enter 0. Your occupation Community Health Index (CHI) Number From your current medical card. NHS Number From your current medical card. Town of Birth From your birth certificate. Country of Birth From your birth certificate. Registered District of Birth From your birth certificate. (Scotland only) Mother's Maiden Name From your birth certificate. What is your ethnic group White Scottish Other white British Irish Other white ethnic group Indian Pakistani Bangladeshi Chinese Other Asian ethnic group Black British or African Black Caribbean Other black ethnic group Other background Students How long are you studying in Glasgow? Have you had the Meningitis ACWY Vaccine? Yes No Have you had the MMR Vaccine? Yes No Name of next of kin Phone number of next of kin