ONLINE REGISTRATION

Welcome to the Online Registration Form. In order to apply for registration, please fill in the form below. This is a combination of the information required by the NHS for all GP registrations and our own Battersea Patient Questionnaire. This provides us with useful background information about your health and lifestyle. We aim to put your details onto our system within 2 working days. Ideally, we would then like to invite you to come to the surgery for a new patient check-up to complete the process. NB if you are already registered with a local GP, have been in the UK for less than 6 months or have never been registered with an NHS GP, please ring the surgery before filling in this form. Failure to do so could result in a delay in your registration being processed.

Please note that this form will be sent to the practice on email. If you are worried about this, please ask us to post the paper forms to you (Click here to send us your name and address).

If you register, this information will be kept as part of your medical record. We cannot register you unless you fill in all the fields, including NHS number, marked *. Fill as many of the others as you can. Do not press RETURN until you reach the end of the page because this will submit your form. Use the TAB key to move down to the next field.

Personal Details

Who would you like to register with:
*Return Email Address:
*Surname:
*Forenames:
Any Previous Surname:
Title:	Mr Mrs Miss Ms Other:
Sex:	Male Female
*NHS Number(essential):
*Date of Birth:
*Address:
*Post code:
Home Telephone:
Work Telephone:
*Town and Country of Birth:
Occupation:
*Ethnic Group:
Next of Kin's Name:
Next of Kin's Telephone:
Next of Kin's Address:

To Help Us Trace Your Previous Medical Records

*Previous Address in UK:
*Previous Doctor's Name:	If no previous doctor, please give the date you entered the UK. You may give the name of the practice rather than the doctor.
*Previous Doctor's Address:	If applicable please fill this in as far as you can remember, so that we can find your old notes.
Reasons for leaving Previous Doctor:

Medical History

Have you had any of the following? Please tick the box and give the year of onset.
Asthma:	/
Diabetes:	/
High Blood Pressure:	/
Angina:	/
Heart Attack:	/
Stroke:	/
Peptic Ulcer:	/
Depression:	/
Anxiety:	/
Other:	Please remember to specify year of onset.

Family History

Have any of your close relatives suffered from:
Diabetes:	Yes No
Angina or Heart Attack:	Yes No If you have any close relative who suffered from angina or heart attack under the age of sixty, tick here

Allergies

Please list any allergies, especially to medicines.
Allergies:

Lifestyle

Cervical Smear Information (for women)

Contraception

Other Information

Height:	(specify units)
Weight:	(specify units)