New Patient Registration

If you would like to register with the practice please use this form.

To register a new patient you will need to live within our practice boundary.

New Patient Registration

Patient's Details

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
Which best describes your gender? *
Is your gender the same as assigned at birth? *

Previous Details

Please include postcode.

If you are from abroad

Registering with the NHS for the first time in the UK
Please use this date format: DD/MM/YYYY.

If you are returning from abroad

Previously been registered with the NHS in the UK
Please use this date format: DD/MM/YYYY.
Please use this date format: DD/MM/YYYY.

Were you ever registered with an Armed Forces GP

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas:

These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

Supplementary Questions

I am not ordinarily a resident in the UK

Ordinarily Resident

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. Alternatively for more information go to www.nhs.uk/visitingengland.

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.

Please select one of the following statements:

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate
action may be taken against me.

A parent/guardian should complete the form on behalf of a child under 16.

European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea
Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?
Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?

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.

EHIC/PRC

Please enter the details from your EHIC or PRC below.

S1 Form

Do you have an S1 Form?
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.

Next of Kin or Emergency Contact

Do you give us permission to discuss your medical records with them?

Are you registering a child under 16? *

Children under 16

Relationship to child:

Language and Communication

Do you have difficulty with speaking or using language to communicate or make your needs known?
Do you need an interpreter or translator?
Can you read English?

Carer information

Are you a carer i.e. do you care for an elderly or disabled person who needs help to live their daily life?
Is the person you care for a Brockwell Park Surgery patient?
Do you have a carer i.e. are you elderly or disabled person who needs help to live your daily life?
Is the person who cares for you a Brockwell Park Surgery patient?

Medical information

Have you had any serious illnesses, injuries or operations in the past?
Do you have any ongoing medical problems?
Do you have any drug or food allergies?

Nominate a Pharmacy

Not sure what your closest pharmacy is?

Use the NHS Find a Pharmacy tool.

Family and past medical history

Have any close relatives (parent, sibling or child only) ever suffered from any of the following:
It is practice policy to offer all new patients an HIV test. Would you like to have an HIV test?

The reception team will contact you to arrange this. Alternatively, you can access Sexual Health London directly to request a free home STI test.

Smoking

Are you a current smoker?
Are you an ex-smoker?

If you would like help to stop smoking, please visit a Lambeth pharmacy offering smoking cessation services. Lambeth pharmacies offering cessation services PDF.

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol

If you would like help and advice on how to reduce your alcohol intake, please contact Drinkaware.

Ethnicity

Which of these best describes your ethnicity?

Disability

Do you have significant mobility issues?
Are you housebound? i.e. unable to leave your home due to physical or psychological illness
Are you blind/partially sighted?
Do you have significant problems with your hearing?

Contraception and Pregnancy

Are you using any contraceptive?
Are you currently pregnant?

Please make an appointment to see a doctor as soon as possible.

If over 20 weeks pregnant, have you had the whooping cough vaccine during this pregnancy?

Please discuss this with one of the doctors as soon as possible.

Patient consent

Where clinically appropriate, we would like to be able to communicate with you via text and email to send reminders about appointment and updates about your medical care.

Can we contact you via text message?
Can we contact you via email?
Do you have a DNACPR (do not attempt CPR) form in place?
Does anybody hold Lasting Power of Attorney for Health and Welfare for you?

Local Care Record

Local NHS organisations have a duty to keep complete, accurate and up-to-date information about your health, so that you can receive the best possible care. Sometimes the people caring for you also need to share some of your information with other health professionals who are also supporting you. The Local Care Record (LCR) allows Primary Care and Local Hospital Trusts to share your patient information online in a secure environment.

LCR enables improved communication and information sharing about your care between Brockwell Park Surgery, Guys & St Thomas’ NHS Foundation Trust, Kings NHS Foundation Trust and South London and Maudsley NHS Foundation Trust. The healthcare professional treating you will inform you when they are accessing your Local Care Record.

If you choose to opt out, the health professionals treating you will not be able to view your electronic Local Care Record. This could mean the people caring for you may not have all the information they need to provide fast, effective and safe care for you (even in an emergency situation). Please be aware that information may still need to be shared for clinical and treatment purposes and therefore this will take place manually, for example by letter.

You can find more information by visiting the kings health partners local care record page.

Please note that this is not the same as the Summary Care Record (see below).

Summary Care Record

Your Summary Care Record (SCR) is an electronic summary of your key health information. It contains important information from your GP records and is available to authorised healthcare staff to prevent mistakes from being made when treating you in an emergency, or when your GP Practice is closed. Your SCR will not be used for any other purposes.

Find more information on SCRs on the NHS SCR page, phone NHS Digital on: 0300 303 5678 or speak to your GP practice.

All patients must select one of the below options:

Your NHS Data Matters - National Data Opt-Out

The national data opt-out is a new service that allows people to opt out of their confidential patient information being used for research and planning. More information is available on the NHS data opt-out page.

Patients can opt out of this service and set their opt-out preferences at through the 'Your NHS Data Matters' site. You will need your NHS number and a valid email address or telephone number.

If you are unable to use the online facility to manage your choice, you can phone 0300 303 5678. A paper print-and- post form is also available through the NHS site directly.

To complete your registration, we request that you upload a proof of your address. This can be a utility bill or bank statement dated within the last 3 months, or your council tax bill dated within the last 12 months. For children under 16, we will contact the person with parental responsibility who is registering the child, to arrange a time to verify your proof of ID (passport or driving licence). In the meantime, please upload a copy of your proof of address.
Maximum upload size: 104.86MB
Signature on behalf of patient