Lister House Staple Tye Harlow Essex CM18 7LU Tel. 0844 576 9010

Application to Register

For convenience, new patients can apply to register here.

Each member of a family will need to have their details entered separately.

Items below which are coloured red MUST be completed - we cannot begin the registration process without this information.


Everybody...
Title:
Surname:
First Name(s):
Previous Surname:
Date of Birth:
Town and Country of Birth:
Home Address:
Post Code:
Telephone:
E-mail Address:
Have you previously been registered here at the Lister Medical Centre?
Please supply the following information to help us to obtain your medical records...
Your Previous Address in the UK:
Your Previous Post Code in the UK:
Name of Previous Doctor:
Address of Previous Doctor:
Previous Health Authority (if known):
Your NHS Number (if known):
If you are from abroad...
Please state your first address in the UK 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 No:
Enlistment Date:

Additional Information:
On receipt of your completed application request, we will send you a pack with details of our practice and some forms (which you MUST complete, sign and return to us otherwise you will not be registered). You may also be required to provide photo-evidence of your identity; proof of your current address; and proof of your eligibility to receive NHS treatment). We will then contact you to arrange a new patient health check.