Psychosexual Medicine Service Patient Registration Form

If you have received a Psychosexual Medicine Service opt-in letter from us, please complete this registration form.

Surname Required

First name(s) Required

Title Required

Date of birth Required

Gender Required

Has this changed since birth? Required

Home address Required

Address 1

Address 2

City

Country

County

Postal Code

I consent to receiving appointment letters/correspondence to this address Required

Mobile number Required

I consent to receive calls and/or texts to this number

Home number

I consent for this number to be called if required Required

E-mail address Required

I consent to receive e-mails Required

What is your marital status? Required

What is your ethnic origin? Required

What is your occupation? Required

What is your nationality? Required

Which GP surgery do you attend? Required

Preferred clinic Required

Second choice of clinic Required

Able to attend at short notice (within 24/48 hours) Required

Please select any consultation options you would be happy with Required

Signature (as this is a digital form, please type your name) Required

I agree to the privacy policy

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