120 Washwood Heath Road, Saltley, Birmingham, B8 1RE

Call : 0121 327 4427 / 5417

Registration form

Please note;

1- * are compulsory questions to answer.

2- You may have to fill in more forms and ID may be required (if you have one)

3- A recent (last 3 months) proof of Home Address may be required. e.g. a utility bill, bank statement or a tenancy agreement.

4- Please note that this website does not store any patient data and this information will be securely passed onto the practice.

*Title

*First Name

Any Middle Name (s)

*Surname

Any Previous Surname (s)

*Date of Birth

*Gender

*Town of Birth including Country Name

NHS No. (if known)

*Current Mobile No

*Current Full Address including Post Code

Current Home No.

Email Address

Previous GP Name (If known)

Previous GP Name (If applicable)

If you are from abroad, your first UK address where registered with GP

Date you first came to live in UK

Would you like to sign up for our online services? Would you like to sign up for our online services? yes no

If you are filling in this form on behalf of a patient, please state your relationship to the patient

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