British Armed Forces Veterans and Reservists

As part of our commitment to Veterans, we wish to ensure that your medical record is updated appropriately. Your basic military details will be kept on your medical record; this is especially helpful to both you and your clinician when a referral is made on your behalf to Secondary Care.
Please complete the details below. Your medical records will also be updated with a ‘code’ highlighting your military Service.
All details provided are treated in the strictest of confidence. This includes your Service Number.

First Name *

Last Name *

Date of Birth

Please use format day/month/year e.g. 12/05/1979

Email *

Enter Email

Phone Number *

Address

Please include your full address, including flat number, house number, room number, block number etc

Enlistment Date

Please use format day/month/year e.g. 12/05/1979

Leaving Date

Please use format day/month/year e.g. 12/05/1979

Service Number

Are you a reservist?

Yes

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. 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.

If you are human, leave this field blank.