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. Please enable JavaScript in your browser to complete this form.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.NameSubmit
