Stalbridge Surgery | New Patient Registration Form

Stalbridge Surgery
Drs Sparrow, Clayton & Furber

Reception: 01963 362363
Admin: 01963 363317
Repeat Prescription: 01963 362138

Station Road, Stalbridge,
Dorset DT10 2RQ

NEW PATIENTS ONLINE REGISTRATION FORM

visit our
HOME PAGE

emis
ACCESS

online
APPOINTMENTS

online repeat
PRESCRIPTIONS

online your
MEDICAL RECORD

our latest
NEWSLETTER

TRAVEL

check planned
HEALTH WALKS

* view our 2008
SITE STATS

useful dorset
WEBSITE LINKS

telephone
DIRECTORY

We welcome new patient registrations. Anyone who lives within our practice area can register with the practice.

Before completing the form below please ensure that you have read our 'how to register' guide.

A copy of our welcome letter is also available online.

The surgery is operating a six month alternate policy of registration, from 1/1/08 with Dr Clayton and from 1/7/08 with Dr Furber. Essentially this is an administrative exercise as any registered patient is free to see whichever Doctor or Nurse they prefer. However, should you feel strongly about being registered with either of the other Doctor's please send us a separate note, via our general contact form, requesting this.

To register online please complete the form below. You won't need to fill in every section but please check the form carefully and give us as much information as you have available. If you want to register the whole family you will need to submit a form for each family member.


Stalbridge Surgery uses a secure connection to encrypt information which is sent from this form.

*Title...
*Forename(s)...		*Surname...
NHS Number... (if known)...
		Previous Surname (if appropriate)...

*Date of Birth...		*Place of Birth...

*Sex...		Male Female

*Address...

*Postcode...

*Email Address...

*Contact Tel. No..

Please help us to trace your previous medical records by providing the following information where appropriate:

Your previous address in the UK...

Address of previous doctor...

Name of previous doctor while at that address...

If you are from abroad, please supply the following information:

Date you first came to live in the UK...

If previously resident in the UK, date of leaving...

If you are returning from the Armed Forces, please supply the following information:

Your address before enlisting...

Service Number... Enlistment Date...

If you are registering a child under 5:

Tick here to register them for Child Health Surveillance

If you need your doctor to dispense medicines and appliances

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

I would have serious difficulty getting them from a chemist

NHS Organ Donor Registration

I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplant after my death.

(Please do not use if you are filling in this form for someone else)

Please select:		Kidneys		Heart		Liver		Corneas
		Lungs		Pancreas		Any part of my body

NHS Blood Donor Registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

(Please do not use if you are filling in this form for someone else)

We will require the patient named in this form to sign in person at the surgery or on a doctor's first home visit. Please indicate the capacity in which you have completed this form:

I have completed this form on my own behalf

	I have completed this form on behalf of:
	My name is...

This website was last updated on : Monday, May 12, 2008
Stalbridge Surgery, Station Road, Stalbridge, Sturminster Newton, Dorset DT10 2RQ
Stalbridge Surgery subscribes to the HONcode principles from the Health On the Net Foundation
Text Links: Home | New Patient Registration | Appointments | Repeat Prescriptions
Email Consultations | Travel Advice | Website Map
© 2008 Stalbridge Surgery | Accessibility | Terms | Staff Login | Site design by Blackmore Vale Internet