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.
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
If “Yes”, ask the receptionist about Carers support
This questionnaire follows the recommendations of the Commission for Racial Equality and complies with the Race Relations Act.
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
If yes, how many:
1 drink = 1/2 pint of beer or one glass of wine or 1 single spirits
Is there any of the following in your family (father, mother, brother, sister) before age of 65?
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:
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:
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 and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
I consent to my information being used for the purposes described above and wish to submit this online form to Gallions Reach Health Centre • Bentham Road, London, SE28 8BE.
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.
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