Gray's Inn, Vauxhall, Daleham Gardens, Fortune Green, Old Kent Road

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New Patient

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Registration Form

Title *

Mr
Mrs
Miss
Ms
Other

First names *

Middle Name(s)

Surname *

Previous surname/s

Date of birth *

Please use this date format: DD/MM/YYYY

NHS Number

Gender *

Male
Female

Main Telephone Number *

Email address *

Other Telephone Number

Personal Status *

Single
Married
Separated
Divorced
Widowed
Other

Place and Country of Birth *

Date of Entry to the UK if not born in the UK

Please use this date format: DD/MM/YYYY

Current Home Address *

Please include postcode

Previous UK Home Address (if applicable)

Please include postcode

Have you previously been registered with a GP in the UK? *

Yes
No

Have you previously served in the armed forces?

Yes
No

Are you completing this form for a child under 16 years old?

Yes
No

Next of Kin – Full Name

Contact Number

Next of Kin contact number

Religion

Christian
Muslim
Jewish
Buddhist
Sikh
Hindu
No Religion
Other
I do not wish to state

Please select from the list below

Summary Care Record *

Opt In
Opt Out

A summary care record (SCR) is an electronic summary of key health information. It will hold limited essential information derived initially from your GP record. This will include medication, adverse reactions and allergies. If you wish to know more information regarding the system and the benefits please ask reception. Alternatively, visit the website: www.nhscarerecords.nhs.uk or call 0845 603 8510

Sharing with other services? *

Share Out
Share In
Both
Neither

Are you happy for us to Share Out your full medical records electronically with other services involved in your care and/or to view (share in) medical records held by other services? We may need to share your medical information with other organisations involved in the delivery of your care e.g. Podiatry or District Nursing. We will not share identifiable information with anyone that isn’t involved in your care unless legally required to.

How did you hear about us? *

Word of Mouth
Walk in Clinic
Practice Leaflet
Advertisement
Internet Search Engine
Other

We would like to send you text messages to your registered mobile about your healthcare. This may include things like appointment reminders and test results. Is this OK? *

Yes
No

Would you like us to send you appropriate emails from the surgery? *

Yes
No

Patient Signature *

Please write your name or parent/carer for under 16s

Date Completed *

Please use this date format: DD/MM/YYYY

Message

The personal information we keep about you is to help us provide health or social care or treatment, under the Data Protection Act (DPA) 2018.

Please fill in the registration form below. Your registration is usually processed within 24 hours (up to 48 hours) if the form is complete.

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Home
Register
Opening Times
Prescriptions
- Contraception
Policies
Change of Details
Self-Referrals