Form registration

Contact details

Practices part of First Care Group Practice

Heathrow Medical Centre

Telephone: 020 8754 1555

Shakespeare Health Centre

Telephone: 0203 794 3119

The Pine Medical Centre

Telephone: 0208 432 8569

Willow Tree Surgery

Telephone: 020 8842 1024

Yeading Court Surgery

Telephone: 020 8845 1515

About this form

Fields marked with a asterisk (*) are compulsory.

Please note that we will not respond to any medical information or questions received through the survey.

The information you supply us will be used lawfully, in accordance with GDPR Regulations. GDPR gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly.

Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of registration.

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.

Please select your practice

Your Details

Title: *

First Name: *

Surname: *

Middle name/s:

Previous surname/s:

Date of birth: *

NHS number:

Gender:

Ethnic origin: *

Personal status:

Place and country of birth:*

Date of entry to the UK if not born in the UK:

Current home address:*

Previous UK home address (if applicable):

Main telephone number: *

Other telephone number:

Email address: *

Have you previously been registered with a GP in the UK?: *

Have you previously served in the armed forces?: *

Are you completing this form for a child under 16 years old?:*

Next of kin

Title: *

First Name: *

Surname: *

Contact number: *

Relationship:*

Medical details

Please let us know of any current medical conditions: * e.g. pregnancy, infection, diabetes or write if not applicable please write n/a

Have you ever struggled with drug or alcohol misuse?: *

What is your smoking status?: *

Do you have a disability?:*

How would you describe your weekly exercise?:*

Height (in cm):*

Weight (in kg):*

Do you have any allergies to medication, food or animals?:*

If answered yes, please state what you are allergic to:*

Please give any details, including dates, of any operations/illnesses you have had: *

Language support

What is your first language?: *

Do you need an interpreter?: *

Do you use any of the following? – Sign language / hearing aid / lip reading:*

Carers

Do you look after a sick, disabled, frail relative or friend without payment? Is there a child or young person in the family who helps to provide care or support to another family member?

Approximately 10% of the current population are carers.

In order to help us update our Carers Register please spend a few minutes of your time completing this information.

Are you a carer?:*

Do you have a carer?*

NHS organ donor registration

For more information, please visit www.uktransplant.org.uk

I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death and confirm consent to organ donation. Please tick if you would like to join:

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

Any part of my body

NHS blood donor registration

For more information, please visit www.blood.co.uk

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood. Please tick:

I confirm consent to my inclusion on the NHS Blood Donor Register

I have given blood in the last 3 years

Other details

Please list any family member registered at the practice or who are soon to be registered (include full name and relationship):

Is there anything else you would like to inform us of?:

How did you hear about us?*

Word of Mouth

Walk in Clinic

Practice Leaflet

Internet Search Engine

Other

Are you happy for us to send you text messages to your registered mobile about your healthcare. This may include things like appointment reminders and test results? *

Are you happy for us to send you appropriate emails from the surgery? *

Patient signature:*

Date completed*

Do you agree to be contacted regarding this matter?:*

Yes, I agree that my practice may contact me regarding this matter

I confirm that I have selected the practice that I would like to be registered with.