Search for:

Skip to content

Home
Appointments
Prescriptions
Services
About
Team
Contact us

Home
Services

Register your next of kin

Please use this form to tell us about your next of kin.

Facebook

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

Patient contact details

Patient name(Required)

First Last

Patient date of birth(Required)

Day

Month

Year

Patient mobile phone number(Required)

Patient home phone number

Patient email address

Enter Email Confirm Email

Next of Kin details

Next of kin name(Required)

First Last

Relationship to patient(Required)

Next of kin address(Required)

Next of kin home phone number(Required)

Next of kin mobile phone number(Required)

Is this person registered at Highlands Surgery?(Required)

Yes

No

Is this person the patient's next of kin?(Required)

Yes

No

Privacy

Can we contact your next of kin in an emergency?(Required)

Yes

No

Can we discuss your medical record with your next of kin?(Required)

Yes

No

Not for urgent medical help(Required)

Yes, I understand this form is NOT for urgent medical help

Consent for next of kin

Patient's digital signature(Required)

The patient must type their name into this box to confirm that the person detailed above is their next of kin and that the details are correct.

Consent(Required)

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.

I agree to the privacy policy.

Date published: 31st October, 2025
Date last updated: 1st April, 2026

Policy

Accessibility
Privacy
Other policies

Helpful links

News
Mid and South Essex Integrated Care Board
You and your general practice

GPsurgery.net © 2026

Manage Cookie Consent

To make our website work efficiently and to provide our website visitors with a good experience when using the website, we use cookies. Cookies are small data files that are placed on your computer or mobile device when you visit a website. Consenting to cookies will allow us to process data such as browsing behaviour or unique IDs. We only share this data with organisations that provide services to the NHS. Not consenting or withdrawing consent to cookies may adversely affect certain features and functions of our website. Please also see the practice’s privacy policy as this may differ to the GPsurgery.net network privacy policy.

Functional Functional Always active

The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network.

Preferences Preferences

The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user.

Statistics Statistics

The technical storage or access that is used exclusively for statistical purposes. The technical storage or access that is used exclusively for anonymous statistical purposes. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you.

Marketing Marketing

The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes.

Manage options Manage services Manage vendors Read more about these purposes

View preferences

Cookie Information Privacy {title}