Milton Keynes, Westcroft Health Centre, Online Registration Form

     Please complete the form below to get
     registered with the Westcroft Health
     Centre.

     On receipt of your completed
     application, we will send you full
     information about the practice. In due
     course you will receive a new medical
     card from the Health Authority.

     *These are mandatory fields. Please
     ensure that you have completed all
     fields marked with an asterisk.

Online Registration

Patient Details

Title

Last Name

First Name(s)

Previous Last Name(s)

Date of Birth*

Town & Country of Birth

Home Address

Post Code

Telephone Number

Email Address*

NHS Number (if known)

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

Your Previous Address in the UK

Name of Previous Doctor while at that Address

Address of Previous Doctor

If you are from Abroad

Your First UK Address where Registered with a GP

If Previously Resident in UK, Date of Leaving

Date, you first came to Live in UK

If you are Returning from the Armed Forces

Address before Enlisting


Service Personnel Number

Enlistment Date

Which Doctor would you prefer to be Registered with?

     Normally new patients will be allocated to whichever Doctor is on take at that
     time. If however you have a particular preference please indicate using the
     check boxes below.

I Prefer to be Registered with:

	Dr. Rowena Liesching		Dr. Jawad Ahmad

NHS Organ Donor Registration

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

Kidneys	Heart	Liver
Corneas	Lungs	Pancreas
Any Part of my Body

     "Warning - This form sends the information via Internet e-mail to Westcroft
     Health Centre. Internet e-mail is not secure and if you are unhappy about
     sending the information in the following from over insecure e-mail then
     please do not use this service."

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