Registration form

The practice catchment area is located in the SE28 area

You need to complete the WHOLE online form below as part of the registration process.

Catchment Area

 

This form is not to be used for clinical queries, if you are unwell please call the practice - Gallions Reach Health Centre 020 8333-5000 / Heronsgate Medical Centre 020 8333-5050

Registration form
If you have not previously had a GP then enter N/A
Please help us trace your previous medical records by providing the following information
If you are from abroad
Were you ever registered with an Armed Forces GP
Carers

If “Yes”, ask the receptionist about Carers support

Allergies
Ethnic Origin

This questionnaire follows the recommendations of the Commission for Racial Equality and complies with the Race Relations Act.

• Afghanistan • Angola • Bangladesh • Benin

• Bhutan • Botswana • Burkina Faso • Burundi

• Cote d'Ivoire • Cabo Verde • Cambodia • Cameroon

• Central African Rep. • Chad • Comoros • Congo

• DRP Korea • DR Congo • Djibouti • Equatorial Guinea

• Eritrea • Ethiopia • Gabon • Gambia

• Ghana • Greenland • Guinea • Guinea-Bissau

• Haiti • India • Indonesia • Kenya

• Kiribati • Laos PDR • Lesotho • Liberia

• Madagascar • Malawi • Mali • Marshall Islands

• Mauritania • Mauritius • Micronesia • Mongolia

• Mozambique • Myanmar • Namibia • Nepal

• Niger • Nigeria • Pakistan • Papua New Guinea

• Philippines • Republic of Moldova • Rwanda • Sao Tome & Princ.

• Senegal • Seychelles • Sierra Leone • Somalia

• South Africa • South Sudan • Swaziland • Thailand

• Timor-Leste • Togo • Tuvalu • Uganda

• UR Tanzania • Zambia • Zimbabwe

Exercise

During the last week, how many hours did you spend on each of the following activities? Please answer whether you are in employment or not

Smoking

If yes, how many:

Ex-Smokers
Alcohol

1 drink = 1/2 pint of beer or one glass of wine or 1 single spirits

Family History

Is there any of the following in your family (father, mother, brother, sister) before age of 65?

Immunisations

Please provide a copy of your immunisation history

If you are registering a child under 5 please advise the dates they have received the following vaccinations:

Female Patients
Communication
Nominated Pharmacy
If you need your doctor to dispense medicines and appliances*

* Not all doctors are authorised to dispense medicines

NHS Organ Donor registration

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death.

Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision.

NHS Blood Donor registration

All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.

SUPPLEMENTARY QUESTIONS

These questions and the patient declaration are optional and your answers will not affect your entitlement to register or receive services from your GP.

PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

Anybody in England can register with a GP practice and receive free medical care from that practice. However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK.

Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges. More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice. You may be asked to provide proof of entitlement

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.

The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

A parent/guardian should complete the form on behalf of a child under 16. If this is the case please provide your:

Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

If yes, please enter details from your EHIC or PRC below:

Please give your S1 form to the practice staff.

How will your EHIC/PRC/S1 data be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process. Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.


Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.