ONLINE - PATIENT REGISTRATION FORM - Kenilworth Medical Centre

ONLINE - PATIENT REGISTRATION FORM

If you would like to register for this online service please complete the form below. Once you are registered the practice will give you the information that will enable you to create a username and password.

Your Details

FORENAME *

SURNAME *

Date of Birth *

ADDRESS (INCLUDING POSTCODE) *

Phone Number *

Email Address *

CONSENT

This form collects your name, date of birth, email, other personal information. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form.

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Page last reviewed: 23 November 2023
Page created: 06 November 2023

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ONLINE - PATIENT REGISTRATION FORM

ONLINE - PATIENT REGISTRATION FORM

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