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

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

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?

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? * Please note, you will still receive a registration confirmation email, and your online patient access login details via email

I have read and checked the above information, and confirm it is correct.

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