COVENTRY & WARWICKSHIRE REGISTRATION & SCREENING SERVICE
Information from GMS1 required by the Registration Department for each type of acceptance
Please help us to help you !Information
Type / Baby / Transfer in from another area / Transfer within same area / Immigrant / Ex-Service / 1st Application
Title / √ / √ / √ / √ / √ / √
Surname / √ / √ / √ / √ / √ / √
First Name(s) / √ / √ / √ / √ / √ / √
Previous Surname(s) / √ / √ / √ / √ / √ / √
Date of Birth / √ / √ / √ / √ / √ / √
NHS NUMBER / √ / √ / √ / √ / √
Sex / √ / √ / √ / √ / √ / √
Place of birth - Town/City* & Country / √ / √ / √ / √ / √ / √
Home Address / √ / √ / √ / √ / √ / √
POSTCODE / √ / √ / √ / √ / √ / √
Previous Address / √ / √ / √ / √ / √
For previous address please provide postcode (and district if in London)
Name of Previous GP / √ / √ / √ / √
Address of Previous GP / √ / √ / √ / √
If from abroad, first address where registered with a GP / √ / √
If previously in UK, date of leaving / √ / √
Date first came to live in UK / √ / √
If Ex-Services, address before enlisting / √ / √
Service/Personnel No / √ / √
Enlistment Date / √
PLEASE NOTE: TELEPHONE NUMBER & ETHNIC ORIGIN NOT CURRENTLY REQUIRED FOR REGISTRATION PURPOSES
Providing the information above, as accurately as possible, particularly the patient’s NHS Number, will ensure that Registration staff can locate and match patient details as effectively and efficiently as possible.Thank you for your assistance.
Information
Type / Immigrant
Title / √
Surname / √
First Name(s) / √
Previous Surname(s) / √
Date of Birth / √
NHS NUMBER
Sex / √
Place of birth - Town/City* & Country / √
Home Address / √
POSTCODE / √
Previous Address
For previous address please provide postcode (and district if in London)
Name of Previous GP
Address of Previous GP
If from abroad, first address where registered with a GP / √
If previously in UK, date of leaving / √
Date first came to live in UK / √
If Ex-Services, address before enlisting
Service/Personnel No
Enlistment Date