Leatside Health Centre

Forth Noweth, Redruth, TR15 1AU

Telephone: 01209 313 313

Sorry, we're currently closed. Please call NHS 111

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Patient details

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Date of Birth*

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Gender*

NHS Number

First Names*

Birth Town*

Surname*

Birth Country*

Current Address and Postcode*

Telephone*

Mobile*

Email Address*

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

Have you previously been registered with an NHS GP in UK?*

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No

Name of Previous GP*

Address of Previous GP*

Your Previous Address

This is usually the address when you were last registered with a GP

Your first UK address*

Date you first came to UK

DD slash MM slash YYYY

Are you returning from the Armed Forces?*

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Please indicate if you have ever served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas*

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Service or Personnel Number*

Enlistment date*

If you are registering a child under 5

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I wish the child above to be registered with the named doctor for Child Health Surveillance

If you need a doctor to dispense medicines and appliances

Nearest Chemist

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

Chemist Difficulty

I would have serious difficulty in getting them from a chemist

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Signatures*

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Signature on behalf of patient

Consent

I agree for the Practice to contact me using the details provided above.

Electronic Signature (Type your full name here)*

By completing the section above, I hereby sign this form electronically

NHS Organ Donor Registration

Would you like to join the NHS Organ Donor Register?*

Yes

No

Already on it

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death.*

Any of my organs and tissue

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

NHS Blood Donor Registration

Would you like to join the NHS Blood Donor Register?*

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Already on it

Tick here if you have given blood in the last 3 years

I have given blood in the last 3 years

My preferred address for donation is:

Phone

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57012

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Opening/Clinic Times

Monday
08:00am to 08:00pm
Telephones only are closed over the lunchtime period 12:30-14:00pm and from 6:00pm
Tuesday
08:00am to 08:00pm
Telephones only are closed over the lunchtime period 12:30-14:00pm and from 6:00pm
Wednesday
08:00am to 08:00pm
Telephones only are closed over the lunchtime period 12:30-14:00pm and from 6:00pm
Thursday
08:00am to 08:00pm
Telephones only are closed over the lunchtime period 12:30-14:00pm and from 6:00pm
Friday
08:00am to 06:30pm
Telephones only are closed over the lunchtime period 12:30-14:00pm and from 6:00pm
Saturday
CLOSED
Sunday
CLOSED

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Name*

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Date of Birth*

Address*

Phone*

Email*

Smoking Status*

How many per day?*

Name

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85738

Friends & Family Test

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We would like you to think about your recent experiences of our service.

Thinking about your recent visit, overall, how was your experience of our service?*

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Very poor

Don't know

Please can you tell us why you gave your answer?

Email

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51111

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