Register Today - Stroud Green Medical Clinic

Registration Form
Non-English Speakers
Disabled Patient Facilities
Non-english speakers

Registration Form

We will check your eligibility for registration and get back to you if there are any issues.

Please ensure that you live within our catchment area for full registration before continuing to register with the practice by entering your postcode via this link; we accept registrations for out of area patients (living in Camden, Islington, Haringey borough), however you will not have access to our home visiting service.

"*" indicates required fields

Part 1: Patient's Details

Is this an out-of-area registration?*

Yes

Preferred Title*

Your Name*

First Name Surname

Previous Surnames Optional

(if applicable)

Date of Birth*

Day

Month

Year

NHS Number Optional

(If known)

Gender*

Country and Town of birth*

Borough of Birth*

Home Address*

Street Address Address Line 2 City Postcode

(Please also provide flat number or room number where appropriate)

Home Telephone Number Optional

Mobile Telephone Number*

Email Address*

Enter Email Confirm Email

Further Details

Ethnicity*

Please specify your ethnicity*

What is your first language?*

Do you require an interpreter?*

EPS Nominated Pharmacy for prescriptions*

Patient pharmacy for Electronic prescriptions.

Contacting You

We will from time to time have to contact patients via SMS text message. this is extremely helpful particularly in the current state of pandemic.

Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders?*

Yes

Previous Medical Records

Please help us trace your previous medical records by providing the following information.

Have you registered with the NHS before?*

Yes

Your previous address in the UK*

Street Address Address Line 2 City Postcode

Name of previous doctor while at that address*

Address of previous doctor

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

Are you from abroad?*

Yes

Your first UK address where registered with a GP

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

Date you first came to live in the UK*

Day

Month

Year

Alcohol Consumption

This is one unit of alcohol:

Half pint of regular Beer/Lager/Cider
1 small glass of wine
1 single measure of spirits
1 single measure of aperitifs
1 small glass of sherry

Each of these is more than one unit:

Pint of regular Beer/Lager/Cider (2 Units)
Pint of Premium Beer/Lager/Cider (3 Units)
Alcopop or can/bottle of regular Lager (1.5 Units)
Can of Premium Lager/Strong Beer (2 Units)
Can of super strength lager (4 Units)
Glass of wine (2 Units)
Bottle of wine (9 Units)

How often do you have a drink containing alcohol?*

Never

Monthly or less

2-4 times per month

2-3 times per week

4+ times per week

How many units of alcohol do you drink on a typical day when you are drinking?*

1-2

3-4

5-6

7-9

10+

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?*

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Smoking

Have you ever been a smoker?*

Smoker

Ex-smoker

Never smoked

How many do you smoke per day?*

When did you stop?*

Your doctors advise all smokers to stop, and free help to do so is available from the surgery, or online at www.breathestopsmoking.org

Are you a carer?*

Yes

Complete Registration

Are you completing this form on behalf of a child under 16?*

Yes

Patient's Name*

First Name Surname

(if signing for the person named at the top of this form)

Relationship to patient*

(if signing for the person named at the top of this form)

Signature*

Signature of patient

Signature on behalf of patient

Signed*

(Full Name)

Comments Optional

This field is for validation purposes and should be left unchanged.

Non-English Speakers

These fact sheets have been written to explain the role of UK health services, the National Health Service (NHS), to newly-arrived individuals seeking asylum. They cover issues such as the role of GPs, their function as gatekeepers to the health services, how to register and how to access emergency services.

Special care has been taken to ensure that information is given in clear language, and the content and style has been tested with user groups.

Open the leaflets in one of the following languages