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New Patient Online Registration

Registering online is for new patients only and takes 5-10 minutes.

Personal Details

Title: *

Contact Details

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

Type N/A in the box if you do not have a previous GP. 

Next of Kin Contact Details

Medical Details

Do you have any of the following medical problems (tick all that apply):

Diabetes

High Blood Pressure

Heart Disease

Asthma

COPD

Cancer

Previous Heart Attack

Previous Stroke

Epilepsy

Depression

Dementia

Mental Health Illness

None

Confirm Medical Conditions

Please include medication name, doses and frequency.

Please include medication , food and other allergies.

Height/Weight (Please estimate if unknown)

Sexual Health (Female)

Are you currently pregnant?

Smoking

Would you like support to quit smoking ?

Alcohol

Please estimate units or use unit calculator:

Your Needs

Are you a carer?
Do you have a carer?
Would you like to be added to our carer's register?

Organ Donation - Optional

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply.

Kidney

Heart

Liver

Corneas

Lungs

Pancreas

Any part of my body

Confirm Options

I do not wish to register

Upload Proof of ID

Proof of ID is strongly recommended. However, Willesden Green Surgery is an inclusive practice, and we will not refuse to register a patient if he/she is unable to provide proof of ID. 

Agreement

Would you like to receive important text messages (including appointment reminder) from the surgery? * Recommended
Would you like to receive important email information from the surgery? *
I have read and checked the above information, and confirm it is correct.

Please ensure all compulsory boxes (marked with *) are complete.

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