Register with Healthcare Group

*Please fill out all fields in the form

Title

First name

Last name

Maiden Name

Date of Birth

Day

Month

Year

Sex

Marital Status

Address

Post Code

Email Address

Telephone Home

Telephone Mobile

Emergency Contact Name

Emergency Contact Phone Number

Relationship to Emergency Contact

If a minor, name of parent / guardian

Name of Previous Doctor

Previous Doctor's Address

Previous Address

If you have moved to Guernsey recently please state: Date of arrival, Intended length of stay and previous address

Do you have any known allergies? If yes please give details

Are you on any medication at the moment? If yes please give details

(For female patients aged 25+) what was the date of your last smear? What was the result (positive or negative)

Do you have any medical conditions? E.g. diabetes, asthma

Do you have medical insurance cover?

Yes

If Yes, please give details of individual membership and policy number

Are you a military veteran?

Yes

States of Guernsey Health Benefit Card Number GY

Which surgery you are registering with?

Rohais

St Martin's

Cobo

High Street

Your doctor preference

I hereby consent to my medical notes being release by my former medical practitioner

Date

Day

Month

Year

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