St Luke's Surgery (Dr Chauhan, Dr Ghosh & Dr Pillai)

Pinfold Health Centre, Field Road, Bloxwich, Walsall, WS3 3JP

Telephone: 01922 775136

Email: clinicalinfo.m91647@nhs.net

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

Home
Appointments or Queries
Prescriptions
Register with the Surgery
Clinics & Services
Patient Info
Contact Us

Get the NHS APP Measles cases are rising in England New Specialised Pharmacist Service COVID Symptoms?….Please wear a face covering. National No Smoking Day Help your Heart this Valentines Stop Smoking New Years Resolution Accredited Veteran Friendly GP Practice Lloyd George digitisation Movember – Mens Health Access to Medical Records Online Stoptober – Stop Smoking Together.. Before entering the practice, please wear a mask…. Community Pharmacy Consultation Service (CPCS)

Home
Online Registration Form

Online Registration Form

Family Doctor Service Registration

"*" indicates required fields

Patient details

Title*

Date of Birth*

DD slash MM slash YYYY

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?*

Yes

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?*

Yes

No

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*

Regular

Reservist

Family Member

Address and Postcode before enlisting*

Service or Personnel Number*

Enlistment date*

If you are registering a child under 5

Child Health Surveillance

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

Signatures

Signatures*

Patient's signature

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?*

Yes

No

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:

Name

This field is for validation purposes and should be left unchanged.

70578

Friends & Family Survey

Opening Times

Monday
08:00am to 06:30pm
Tuesday
08:00am to 06:30pm
Wednesday
08:00am to 06:30pm
We close on the second last Wednesday of the month for staff training. Please phone Ournet 01922 501999 if you require assistance
Thursday
08:00am to 06:30pm
Friday
08:00am to 01:00pm
If you need assistance between 1:00pm to 6:30pm, please call Ournet on 01922 501999
Saturday
CLOSED
Sunday
CLOSED

Useful Links

NHS Choices

NHS 111

Patient UK

Patient Online Triage Form

Veteran Friendly Practice

Safe Surgeries

NHS A-Z Conditions

Find Local Services

Live Well

Staff Login | Privacy Policy | Accessibility

Accessibility Tools

Cleantalk Pixel

Cookies To make this site work properly, we sometimes place small data files called cookies on your device. Most big websites do this too.

Accept

Read more

Change Settings

Cookie Box Settings

Cookie Box Settings

Privacy settings

Decide which cookies you want to allow. You can change these settings at any time. However, this can result in some functions no longer being available. For information on deleting the cookies, please consult your browser’s help function. Learn more about the cookies we use.

With the slider, you can enable or disable different types of cookies:

Block all
Essentials
Functionality
Analytics
Advertising

This website will:

Essential: Remember your cookie permission setting
Essential: Allow session cookies
Essential: Gather information you input into a contact forms, newsletter and other forms across all pages
Essential: Keep track of what you input in a shopping cart
Essential: Authenticate that you are logged into your user account
Essential: Remember language version you selected

This website won't:

Remember your login details
Functionality: Remember social media settings
Functionality: Remember selected region and country
Analytics: Keep track of your visited pages and interaction taken
Analytics: Keep track about your location and region based on your IP number
Analytics: Keep track of the time spent on each page
Analytics: Increase the data quality of the statistics functions
Advertising: Tailor information and advertising to your interests based on e.g. the content you have visited before. (Currently we do not use targeting or targeting cookies.
Advertising: Gather personally identifiable information such as name and location

This website will:

Essential: Remember your cookie permission setting
Essential: Allow session cookies
Essential: Gather information you input into a contact forms, newsletter and other forms across all pages
Essential: Keep track of what you input in a shopping cart
Essential: Authenticate that you are logged into your user account
Essential: Remember language version you selected
Functionality: Remember social media settings
Functionality: Remember selected region and country

This website won't:

Remember your login details
Analytics: Keep track of your visited pages and interaction taken
Analytics: Keep track about your location and region based on your IP number
Analytics: Keep track of the time spent on each page
Analytics: Increase the data quality of the statistics functions
Advertising: Tailor information and advertising to your interests based on e.g. the content you have visited before. (Currently we do not use targeting or targeting cookies.
Advertising: Gather personally identifiable information such as name and location

This website will:

Essential: Remember your cookie permission setting
Essential: Allow session cookies
Essential: Gather information you input into a contact forms, newsletter and other forms across all pages
Essential: Keep track of what you input in a shopping cart
Essential: Authenticate that you are logged into your user account
Essential: Remember language version you selected
Functionality: Remember social media settings
Functionality: Remember selected region and country
Analytics: Keep track of your visited pages and interaction taken
Analytics: Keep track about your location and region based on your IP number
Analytics: Keep track of the time spent on each page
Analytics: Increase the data quality of the statistics functions

This website won't:

Remember your login details
Advertising: Use information for tailored advertising with third parties
Advertising: Allow you to connect to social sites
Advertising: Identify device you are using
Advertising: Gather personally identifiable information such as name and location

This website will:

Essential: Remember your cookie permission setting
Essential: Allow session cookies
Essential: Gather information you input into a contact forms, newsletter and other forms across all pages
Essential: Keep track of what you input in a shopping cart
Essential: Authenticate that you are logged into your user account
Essential: Remember language version you selected
Functionality: Remember social media settings
Functionality: Remember selected region and country
Analytics: Keep track of your visited pages and interaction taken
Analytics: Keep track about your location and region based on your IP number
Analytics: Keep track of the time spent on each page
Analytics: Increase the data quality of the statistics functions
Advertising: Use information for tailored advertising with third parties
Advertising: Allow you to connect to social sitesl Advertising: Identify device you are using
Advertising: Gather personally identifiable information such as name and location

This website won't:

Remember your login details

Save & Close