Registration 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. TitleMsMissMrsMrDrRevMxFirst Name *Middle NameLast Name *Date of Birth *in the format DD/MM/YYGender *MaleFemaleTown and Country of birth *Home address *Address in the UKPost Code *You can register with us even if you live outside our practice area! To be eligible for home visits, you must live within the practice catchment area NHS NumberMobile Phone *Home Phone Work PhoneEmail *Previous Address *If this is not applicable please enter N/AName and Address of previous GP Surgery [Type 'None' if first NHS GP Practice registration] *Main Spoken Language *Do you require an Interpreter? *YesNoDate of entry into the UK *[PLEASE COMPLETE IF THIS IS YOUR FIRST UK GP REGISTRATION]HIV Screening *HIV Screening AcceptedHIV Screening DeclinedAll new patients are eligible for free a HIV test which can be done in surgery by our Practice Nurse/HCA via a blood testCurrent Smoking Status *Current SmokerEx-SmokerNever Smoked TobaccoAlcohol consumption (Average Units per week)How often do you have 6 or more units of alcohol if female, or 8 or more if male, on a single occasion in the last year? *NeverLess than monthlyMonthlyWeeklyDaily or almost dailyHow often during the last year have you failed to do what was normally expected from you because of you drinking? *NeverLess than monthlyMonthlyWeeklyDaily or almost dailyHow often during the last year have you been unable to remember what happened the night before because you had been drinking *NeverLess than monthlyMonthlyWeeklyDaily or almost dailyHas a relative or friend, doctor or other health worker been concerned about your drinking or suggesting that you cut down? *The Integrated Camden Alcohol Service allow patients to self-refer to book appointments by calling 020 3227 4950, see their website for detailsNoYes, but not in the last yearYes, during the last yearhttps://www.candi.nhs.uk/services/camden-specialist-alcohol-treatment-service-csatsNominated PharmacyStarr Pharmacy - 81 Grays Inn Rd, WC1X 8TPBoutalls Pharmacy - 60 Lambs Conduit Street, WC1N 3LWBoots - 24 High Holborn, WC1V 6AZRowlands Pharmacy - 16 Exmouth Market, EC1R 4QEClarkenwell Pharmacy - 51 Exmouth Market, EC1R 4QLHolborn Pharmacy - 88 Southampton Row, WC1B 4BBClockwork - 150 Southampton Row, WC1B 5ANOther [please include name and postcode]The Grays Inn Medical Practice can send your medication electronically to a nominated pharmacy of your choice ready for collectionNominated PharmacyNext of Kin/Emergency Contact *FirstLastNext of Kin Contact Number *Relationship to Patient *How did you hear about us?Patient Signature *Please write your name or parent/carer for under 16s Confirmation *I agree to switch my registered GP practice.By confirming, you are consenting to leave your current NHS GP practice. You are free to change your NHS GP practice at any time.EmailSubmit
