Register as a temporary patient form

If you are ill while away from home or if you are not registered with a doctor but need to see one, you can receive emergency treatment from the local GP practice and will need to register as a temporary or permanent patient.

You can be registered as a temporary patient for up to three months. This will allow you to be on the local practice list and still remain a patient of your permanent GP.

To register as a temporary patient simply contact the local practice you wish to use. Practices do not have to accept you as a temporary patient although they do have an obligation to offer emergency treatment. You cannot register as a temporary patient at a practice in the town or area where you are already registered.

Please complete the below form to register as a temporary patient at Burbage Surgery.

Surname

First name(s)

Previous names (if applicable)

Your date of birth

Sex

Male

Female

Telephone

Email address

NHS No.

An NHS number is a 10-digit number, like 485 777 3456. If known, please enter your NHS number in the field below. You can find more information on the NHS website

Your current home address

Home address (permanent)

Current GP practice name

Current GP practice address

Start date of temporary registration

End date of temporary registration (if known)

Reason for temporary registration

I consent to the temporary registration and care provided by the GP practice

Signature

Write your full name

Date of submitting the form