Children under 16 Children under 16

The Government have asked that we record the ethnic origin of all patients who The Government have asked that we record the ethnic origin of all patients who
register with us. We would therefore be grateful if you could tick the relevant register with us. We would therefore be grateful if you could tick the relevant
box. If you do not feel happy to give us this information you can tick the last box. If you do not feel happy to give us this information you can tick the last
box. box.

Name ---------------------------------------- Date of Birth ---------------- Name ---------------------------------------- Date of Birth ----------------

Next of Kin Name ------------------------------------------------------------ Next of Kin Name ------------------------------------------------------------

Contact Number -------------------------------------- Contact Number --------------------------------------

White Pakistani White Pakistani

Black African Bangladeshi Black African Bangladeshi
Black Caribbean Chinese Black Caribbean Chinese
Black Other Other Asian Black Other Other Asian
Indian Information Refused Indian Information Refused

Prescription Destination Prescription Destination

Should your child require Prescription medication where do you wish to collect Should your child require Prescription medication where do you wish to collect
your Prescription Medicines from? your Prescription Medicines from?

Please choose ONE of the following: Please choose ONE of the following:

Lloyds Pharmacy GRAYSHOTT Lloyds Pharmacy GRAYSHOTT

Lloyds Pharmacy BEACON HILL Lloyds Pharmacy BEACON HILL

Badgerswood Pharmacy, HEADLEY Badgerswood Pharmacy, HEADLEY

Boots High Street, HASLEMERE Boots High Street, HASLEMERE

Lloyds Pharmacy, HIGH STREET, HASLEMERE Lloyds Pharmacy, HIGH STREET, HASLEMERE

Lloyds Pharmacy, WEY HILL, HASLEMERE Lloyds Pharmacy, WEY HILL, HASLEMERE

SURGERY (Paper Prescription only) SURGERY (Paper Prescription only)

PLEASE NOTE: We do not have a dispensary onsite PLEASE NOTE: We do not have a dispensary onsite
 REGISTRATION CHECKLIST REGISTRATION CHECKLIST

1. Reception 1. Reception

ID/NHS No Proof of Residence ID/NHS No Proof of Residence

2. Jane/Lorna 2. Jane/Lorna

Named GP Named GP

Date of Registration Date of Registration

Ethnicity Ethnicity

3. Input to Patient Record 3. Input to Patient Record

Next of Kin Next of Kin

Prescription Destination Prescription Destination

Print Welcome Letter Print Welcome Letter

Input Date _________________________ Initials ________ Input Date _________________________ Initials ________