Aspull Surgery
01942 831263

The Hub
01942 482848

New patient pre-registration form

Please complete this form as fully as possible. You MUST also complete the Health Questionnaire.

  • 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
    Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision.
    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.