Medical Centre Name Here

How Do I.... Register With The Practice?

If you live within our practice area (please check with our receptionists if you are unsure), we will register you on production of proof of address and identity, and a completed registration form that is available at reception. If you are from abroad, you will need to show your passport. Registration takes up to 48 hours to complete. After this you will be able to book an appointment with a clinician. You will be registered with the practice rather than with an individual doctor. You are free to see any doctor you wish. Please make your application for registration between 10.00am and 5.00pm on weekdays only.

Streatham Common Group Practice St Andrews Hall Guildersfield Road Streatham Common SW16 5LS Telephone: 0208 765 4900 PATIENT DETAILS Mr Mrs Miss Ms Surname: Date of Birth: -- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -- 01 02 03 04 05 06 07 08 09 10 11 12 ---- 1895 1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 First names: NHS No: - - Previous Surname: Sex:  Select Sex MaleFemale Town & Country of Birth: Height: Weight: I am NOT a student I AM a student at: Email Address: (your-email@address.co.uk) Current Address:   Postcode: Work Telephone: Home Telephone: Mobile: PREVIOUS MEDICAL RECORDS Your previous address in UK Previous GP Details Postcode: Name of previous doctor while at that address: Address of that doctor: Postcode: ARE YOU FROM ABROAD? Please select Yes No Please make your selection above. Please move to the next section. Your first UK address where registered with a GP Other Details Postcode If previously resident in UK, date of leaving Date you first came to live in UK ARE YOU RETURNING FROM THE ARMED FORCES? Please select Yes No Please make your selection above. Please move to the next section. Address before enlisting Service Details Postcode Service or Personnel Number Enlistment date Medical Information List any serious illnesses or operations that you have had in the past including date: No serious illnesses or operations - Date: N/A Are you regulary taking any tablets/medicines? If yes please give details of the type of tablets/medicine includint type and strength: No tablets/medicine taken - Date: N/A Are you allergic to any tablets/medicines? If yes please give details of the type of tablets/medicine that you are allergic to: Not allergic to any tablets/medicines - Date: N/A Does anyone in your family Father, Mother, Brother, Sister have a history of?   Heart disease (Heart attack, Angina or Heart failure)?    Under 60  Over 60   Stroke or "Mini-stroke"   High Blood Pressure (Hypertension)   Diabetes Current Smoker: How many do you smoke per day? How long have you been a smoker? Would you like us to help you stop smoking?   Yes   No Ex-Smoker: How many did you smoke per day? When did you give up? How long were you a smoker? Do you drink alcohol? If yes how many a drinks per week? (1/2 ber, 1 glass wine, 1 measure of spirit = 1 unit) For Women Was the results normal?  YesNo When was your last cervical smear test? -- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -- 01 02 03 04 05 06 07 08 09 10 11 12 ---- 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 If you need your doctor to dispense medicines and appliances* I live more than 1 mile in a straight line from the nearest chemist - Please select Yes No I would have serious difficulty in getting them from a chemist - Please select Yes No *not all doctors are authorised to dispense medicines NHS Organ Donor Registration I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death. Please select Yes No Please check as appropriate:- Kidneys Heart Liver Corneas Lungs Pancreas Any part of my body Register Your Child Would you like to register your child with the practice: Yes No Please fill out this section if you are registering your child with the practice: Date of Birth: -- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -- 01 02 03 04 05 06 07 08 09 10 11 12 ---- 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 First Name: Height: Last Name: Parent/Guardian or Carere Telephone No: Who does the child live with:? Was the pregnancy normal?  Yes No What school/Nusery does the child attend? Was the birth normal?  Yes No Has the child had any serious illness or operations? If yes please give details: Is he/she regularly taking any tablets or medicines? If yes please give details: Are they allergic to any tablets/medicines? If yes please give details: What immunisation has he/she had and when? Usual Age Immunisation Date Immunised 2 Months DTaP/IPV/Hib and PCV -- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -- 01 02 03 04 05 06 07 08 09 10 11 12 -- 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 3 Months DTaP/IPV/Hib, PCV and Men C -- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -- 01 02 03 04 05 06 07 08 09 10 11 12 ---- 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 4 Months DTaP/IPV/Hib, PCV and Men C -- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -- 01 02 03 04 05 06 07 08 09 10 11 12 ---- 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 12 Months Hib/Men C -- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -- 01 02 03 04 05 06 07 08 09 10 11 12 ---- 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 13 Months MMR and PCV -- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -- 01 02 03 04 05 06 07 08 09 10 11 12 ---- 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 3 1/2 Years DTaP/IVP or dTaP/IPV and MMR -- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -- 01 02 03 04 05 06 07 08 09 10 11 12 ---- 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Girls 12-13 Years HPV -- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -- 01 02 03 04 05 06 07 08 09 10 11 12 ---- 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 13-18 Years Td/IPV -- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -- 01 02 03 04 05 06 07 08 09 10 11 12 -- 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Sending this form does not guarantee or even imply that you will be accepted onto the practice register. Click 'Submit' to send your details to the surgery, you will then be prompted to complete a Questionnaire form.