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Register as a New Patient

Please fill out the registration form, it will take approximately 5-10 minutes to complete. Please allow up to 3 working days for the processing of your registration. You will receive a text message once you are a registered patient at the practice and can then begin to use our services:

Adult Patient Registration Form (Person Over 16)
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Personal Details
Title*
Forename*
Surname*
Previous Surname
Date of Birth*
Date Format: DD dash MM dash YYYY

Gender*
Town & Country Of Birth
eg. London, United Kingdom
NHS Number

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Contact & Address Details
Mobile Phone Number*
Home/Work Phone Number
Email*

Current Address*
Please enter your current address

Postcode

0PYQ-7B2D-11IN-IPLK

PaulHeenan1052721

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Name/Number and Street Address Line 2 Town/City

Time living at current address*
Please indicate if you have lived at your current address for less than or more than 6 months
Previous Address
If living at current address for less than 6 months

Postcode

0PYQ-7B2D-11IN-IPLK

PaulHeenan1052721

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Name/Number and Street Address Line 2 Town/City County

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Previous GP Information
Name of previous GP Surgery in the UK*
Please enter the name of your previous GP Practice in the UK, once you enter the name you will prompted to add the address. (if not previously registered please write 'UNKNOWN')
Address of previous GP in the UK*
Postcode

0PYQ-7B2D-11IN-IPLK

PaulHeenan1052721

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Name/Number and Street Address Line 2 Town/City County / State / Region

Arrival into the UK (if applicable)
For patients who have recently arrived or returned to the UK. If not applicable please continue to the next page.
Date of arrival into the UK
Date Format: DD slash MM slash YYYY

If you previously lived in the UK what date did you leave?
Date Format: DD slash MM slash YYYY

If you are returning from the armed forces, what was your address before enlisting?
Postcode

0PYQ-7B2D-11IN-IPLK

PaulHeenan1052721

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Name/Number and Street Address Line 2 Town/City County

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Other Details
Occupation
Country of Birth*
Nationality*
Preferred Language*
Do you use BSL (British Sign Language)?*
Would you like an interpreter?*
Do you require any other assistance with communication?*
Ethnicity*
Religion*
Sexuality*
Are you registered as an asylum seeker?*

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Next of Kin Details
Title of Next of Kin*
Surname of Next of Kin*
Forename of Next of Kin*
Mobile Phone of Next of Kin*
Home Phone of Next of Kin
Email of Next of Kin*

Current Address of Next of Kin*
Postcode

0PYQ-7B2D-11IN-IPLK

PaulHeenan1052721

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Name/Number and Street Address Line 2 Town/City County

Are you a carer, do you help a friend or relative with their daily activities?
Their Name
Relationship to You

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About Your Health
To help us better understand and meet your health needs it would be useful to know about your medical conditions. Please indicate below any health issues you take medication for and any signifcant or long-term medical conditions you have suffered with. This is particualrly important if you have recently moved or returned to the UK.
Asthma
Yes
Date of Asthma Diagnosis
Date Format: DD slash MM slash YYYY

Cancer
Yes
Date of Cancer Diagnosis
Date Format: MM slash DD slash YYYY

Type of Cancer
Diabetes
Yes
Type Of Diabetes
Do you attend a specialist diabetic clinic?
If YES location of clinic
Gynaecology
Yes
Type of Gynaecology
Smear Test Results

Heart Disease
Yes
Type of Heart Disease
HIV
Yes
Date of HIV Diagnosis
Date Format: MM slash DD slash YYYY

Thyroid Disease
Yes
Date of Thyroid Disease diagnosis
Date Format: MM slash DD slash YYYY

Type of Thyroid Disease
Blood Pressure
Yes
Do you own a home blood pressure machine?
Mental Illness
Yes
Type of Mental Illness
Date diagnosed with Mental Illness
Date Format: MM slash DD slash YYYY

Gastroenterology/Bowel disorder
Yes
Type of Gastroenterology/Bowel disorder
Date of Gastroenterology/Bowel disorder diagnosis
Date Format: MM slash DD slash YYYY

Other
Please state any other medical conditions, and include date(s) of diagnosis where possible
Note: It is helpful and allows us to be more efficient if you are able to email your medical records from abroad. We are only able to accept them in English - please arrange for any translation. completed the registration process.
Medication
Please list any medication you may be taking.
Please list all current medication prescribed to you.
Medication Name Dose

Please indiate if you will be requiring a prescription within 7 days*
Allergies
Do you have any allergies?*
If you answered YES, to previos question please give details about your allergies here
Are you allergic to any medications?*
If you answered YES, to previos question please give details about your medication allergies here
Weight & Height
Please enter your height in either Feet and Inches or in Centimetres.
Height in Feet and Inches
Please enter your height in number format. (eg 5 foot 3 inches would be 5.3)
Or
Height in CMs
Please enter your height in number format. (eg 160cm would be 160 without the cm)
Please enter your weight in either Stones and pounds or in KG.
Weight in Stones & Pounds
Please enter your weight in number format. (10 stone, 3 lbs would be 10.3)
Or
Weight in KG
Please enter your weight in number format. (60kg would be 60 without the kg)
Exercise
Do you exercise regularly?*
If YES, How Many times a week do you excercise?

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Smoking
Do you smoke Cigerettes?
If YES - How many do you smoke a day?
Would you like information to help you quit smoking?
When did you stop Smoking?
Alcohol
Do you drink alcohol?*

Using the scoring system above, please score yourself between 0-4 for the following questions.
How often do you have a drink containing alcohol?*
How many units of alcohol do you drink on a typical day when you are drinking?*
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?*
Total Audit C Questions*
As you have scored greater than 5 in our first audit test we now ask that you answer the following questions
How often during the last year have you found that you were not able to stop drinking once you had started?*
How often during the last year have you failed to do what was normally expected from you because of your drinking?*
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?*
How often during the last year have you had a feeling of guilt or remorse after drinking?*
How often during the last year have you been unable to remember what happened the night before because you had been drinking?*
Have you or somebody else been injured as a result of your drinking?*
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?*
Total Acohol Audit Score*
Alcohol Risk Score*
Lower Risk (0-7)
This level of drinking means that in most circumstances you have a low risk of causing yourself future harm
Increasing Risk (8-15)
You are drinking at a level that increases the risk of damaging your health and could lead to serious medical conditions
Higher Risk (16-19)
This level of drinking has the greatest list of health problems
Possible Dependence (20+)
This level of drinking has the greatest list of health problems and you may need to be reffered for help

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HIV Testing
Would you like to have a HIV test?*
Please note if you have been exposed within the last three months you should arrange to REPEAT it after 3 months time
Patient Access
Patient Access is a website and mobile app (download from iOS and Android app stores for free) which gives you access to a range of GP services online, as well as access to your health records. Using Patient Access will allow you to: - Order your repeat prescriptions - Book your GP appointments - Access your medical records
Would you like to use this service?*
Note: A member of the reception team will be in touch with how to complete this process.
Communications
Clapham Family Practice uses text messages to communicate with you for; appointment reminders; results of investigations (care will be taken to be sensitive); to gather further clinical information e.g. photos; and direct you to the appropriate services e.g mental health. A record of these messages are stored in your medical records. Your mobile number is not passed to any other parties.
Consent to Text Messaging Service*
I consent to the receiving and sending of text messages
Note: Please be aware that if you opt out of text messaging from the practice, you will no longer have appointment reminders, appointment cancellations, results, recieve documents i.e. sick notes. The practice is not responsible for the delivery of any letters posted to you via Royal Mail. The practice relies heavily on text communications for speed and delivery of information to our patients.
Consent to Voicemail Service*
I consent to the receiving of voicemails from the practice
Consent to receiving emails*
I consent to the receiving of emails from the practice
Proof of Address
Please attach 1 form of proof of address, eg. a current utility bill, current tax certificate, a current bank statement. We except files in jpg, png and pdf format.

Drop files here or

Accepted file types: jpg, png, pdf.

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Summary Care Records
Summary Care Records (SCR) are an electronic record of important patient information, created from GP medical records. They can be seen and used by authorised staff in other areas of the health and care system involved in your care.
Consent for Summary Care*
*Additional Information includes: significant medical history (past and present) reason for medication Management of long term conditions end of life care information immunisations.
Express consent for medication, allergies adverse reactions and *additional information.
Express consent for medication, allergies and adverse reactions only
Express dissent – patient does NOT want a Summary Care Record and fully understands the risks involved in this decision.
NHS healthcare staff caring for you may not be aware of your current medications, your allergies or adverse reactions to medications you have had, in order to treat you safely in an emergency. Please confirm*
Your Data Matters to the NHS
Information about your health and care helps us to improve your individual care, speed up diagnosis, plan your local services and research new treatments. Your health records contain a type of data called confidential patient information. This data can be used to help with research and planning. You can choose to stop your confidential patient information being used for research and planning. You can also make a choice for someone else like your children under the age of 13.

If you wish to OPT OUT you can complete this online. http://www.nhs.uk/your-nhs-data-matters/manage-your-choice

Additionally you can OPT OUT by contacting the NHS Digital Contact Centre. Call: 0300 303 5678 Open 9am-5pm Monday – Friday (Excluding Bank Holidays)
Disclosure Agreement
Consent to disclose all material regarding healthcare*
I agree to disclose all material facts regarding my healthcare to practice clinicians. The practice agrees that we will not share any information about you without your consent. Referrals to social services or specialist services which are made at your request imply consent.*
Confidentiality Agreement
Confidentiality Consent*
Is a fundamental part of HealthCare & crucial to the trust between Doctors & Patients. All staff working in the NHS have Legal, Ethical & Contractual obligations of Confidentiality and must ensure that they act appropriately to protect Patient Information against improper disclosure.*
Appointments
Appointments Consent*
I agree to attend on time for all appointments. I agree to call the practice to cancel any appointments that I cannot attend. I acknowledge that should I arrive late for an appointment I may be asked to rebook. I accept that the practice has the right to remove me from the list if I do not adhere to this agreement. The practice agrees to notify you if your appointment is being cancelled by the practice and offer you an appropriate alternative.*
Emergency Appointments Consent*
I acknowledge that the practice operates on an appointment system. I acknowledge that a limited number of emergency appointments may be available each morning for conditions that are regarded by the patient as medical emergencies which have arisen in the previous 48 hours and require immediate medical treatment. I appreciate that this is a triage service and may result in a request that I make a routine appointment. I am aware that sick notes or repeat prescriptions will not be entertained in emergency appointments.*
Home Visits
Home Visits Consent*
Home visits by a GP or nurse will only take place strictly for our housebound and end of life patients. If a visit is required please request this before 11.00am of the day of the visit. I acknowledge that if I request a home visit the on call doctor will telephone me and advise me of the most appropriate care option. Home visits can only be to your registered address and within our catchment area.*
Zero Tolerance
Zero Tolerance Consent*
The practice has a zero tolerance for prejudice on the basis of race, creed, gender or sexuality. This applies to patients as well as staff. I accept that the practice can remove me from the list if I behave in an abusive, aggressive, threatening manner to any other patient or to a staff member.*
Marketing
How did you hear about us?
Please Specify
Please specify how you heard about us below
Your Personal Data*
Please note that any personal data you provide will be treated in the strictest of confidence and in full compliance with GDPR legislation. Any identifying information you specify will be held by us for the sole purpose of answering your enquiry. The data will be stored on our server until such time that it is no longer required. If you are happy for us to use and store your data in this way, Please tick the box below. Full details are available in our Privacy Policy.
I consent to Clapham Family Practice storing and using my personal data for the sole purpose of addressing my enquiry.

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Child Patient Registration Form (Person Under 16)
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Personal Details of Person (Under 16)
If you are filling out this form on behalf of your child, please ensure that it’s their details you provide (not yours) as they are the patient.
Forename*
Middle name
Surname*
Date of Birth*
Date Format: DD slash MM slash YYYY

Gender*
Town & Country Of Birth
eg. London, United Kingdom
NHS Number

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Contact Details
Please enter the contact details of the person who is responsible for this patient.
Mobile Phone Number (of responsible adult)*
Home/Work Phone Number (of responsible adult)
Email (of responsible adult)*

Address Details of Person (Under 16)
Current Address*
Please enter your current address

Postcode

0PYQ-7B2D-11IN-IPLK

PaulHeenan1052721

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Name/Number and Street Address Line 2 Town/City County

Time living at current address
Please indicate if you have lived at your current address for less than or more than 6 months
Previous Address
If living at current address for less than 6 months

Postcode

0PYQ-7B2D-11IN-IPLK

PaulHeenan1052721

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Name/Number and Street Address Line 2 Town/City County

Save and Continue Later

Previous GP Information of Person (Under 16)
Name of Previous GP Practice*
Please enter the name of you previous GP in the UK, once you enter the name you will prompted to add the address. (if not previously registered please write 'UNKNOWN')
Address of Previous GP Practice*
Postcode

0PYQ-7B2D-11IN-IPLK

PaulHeenan1052721

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Name/Number and Street Address Line 2 Town/City County / State / Region

Arrival into the UK (if applicable)
For patients who have recently arrived or returned to the UK.
Date of arrival into the UK
Date Format: MM slash DD slash YYYY

If previously lived in the UK what date did he/she leave?
Date Format: MM slash DD slash YYYY

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Other Details of Person (Under 16)
Country of Birth*
Nationality*
Preferred Language*
Does this patient use BSL? (British Sign Language)*
Would this patient like an interpreter?*
Does this patient require any other assistance with communication?*
Ethnicity*
Religion*

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Parent/Guardian Details
Details of 1st Parent/Legal Guardian/Foster Parent
1st Parent/Legal Guardian/Foster Parents
Title*
Forename*
Surname*
Relationship*
Current Address*
Postcode

0PYQ-7B2D-11IN-IPLK

PaulHeenan1052721

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Name/Number and Street Address Line 2 Town/City County / State / Region

Home Phone
Mobile Phone
Email

Details of 2nd Parent/Legal Guardian/Foster Parent
2nd Parent/Legal Guardian/Foster Parents
Title
Forename
Surname
Relationship
Current Address
Postcode

0PYQ-7B2D-11IN-IPLK

PaulHeenan1052721

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Name/Number and Street Address Line 2 Town/City County / State / Region Country

Home Phone
Mobile Phone
Email

Next of Kin Details
If the next of a kin details are different to above please tick this box.
Consent Next of Kin Details
Enter Next of Kin Details
Title of Next of Kin
Surname of Next of Kin
Forename of Next of Kin
Mobile Phone of Next of Kin
Home Phone of Next of Kin
Email of Next of Kin

Current Address of Next of Kin
Postcode

0PYQ-7B2D-11IN-IPLK

PaulHeenan1052721

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Name/Number and Street Address Line 2 Town/City County

Consent Next of Kin Records
Do you consent to share records with your next of kin?

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Details of School/Carer (Person under 16)
Type of Care
Name of School/Carer
Address of School/Carer
Postcode

0PYQ-7B2D-11IN-IPLK

PaulHeenan1052721

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Name/Number and Street Address Line 2 Town/City County

Phone Number of School/Carer
Details of Siblings
Surname First Name Date of Birth Registered at CFP (Y/N)

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Parental Consent
A responsible adult is usually a parent or guardian but it can also be a grandparent or nanny, or whoever is most likely to bring your child to the practice.
Parental Consent for Responsible Adult Consultation Attendance
RESPONSIBLE ADULT #1

This is a formal contract between Clapham Family Practice and you.
Name of Responsible Adult #1
Relationship of Responsible Adult #1 to Child
eg. Grandfather
Consent to speak on my behalf
By ticking this box you give consent for the above named person to attend or speak on my behalf, for a consultation with a GP or Nurse. They can agree to any treatment or vaccination required on my behalf
I give consent for the above named person to attend or speak on my behalf
RESPONSIBLE ADULT #2

This is a formal contract between Clapham Family Practice and you.
Name of Responsible Adult #2
Relationship of Responsible Adult #2 to Child
eg. Childminder
Consent to speak on my behalf
By ticking this box you give consent for the above named person to attend or speak on my behalf, for a consultation with a GP or Nurse. They can agree to any treatment or vaccination required on my behalf
I give consent for the above named person to attend or speak on my behalf

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Medical History of Person (Under 16)
To help us better understand and meet your health needs it would be useful to know about your medical conditions. Please indicate below any health issues you take medication for and any signifcant or long-term medical conditions you have suffered with. This is particualrly important if you have recently moved or returned to the UK.
Have you arrived or returned to the UK within the last 6 months*
It is helpful and allows us to be more efficient if you are able to email your medical records from abroad. We are only able to accept them in English - please arrange for any translation. completed the registration process.
Please list all current medication prescribed to you.
Medication Dose

Do you require a prescription in the next 7 days?*

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Vaccinations of Person (Under 16)
To the best of your knowledge are all your vaccinations up to date?
If the registering patient is under 6 years old please can you submit a copy of the vaccination record (Red baby book) to the practice email LAMCCG.CLAPHAMFMAILY@NHS.NET
Please book an appointment with the Practice Nurse to arrange for vacciantions

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Consent for Use of Service
Patient Access is a website and mobile app (download from iOS and Android app stores for free) which gives you access to a range of GP services online, as well as access to your health records. Using Patient Access will allow you to: - Order your repeat prescriptions - Book your GP appointments - Access your medical records
Would you like to use this service?
Note: A member of the reception team will be in touch with how to complete this process.
Communications
As a paper light service the practice uses a text service/telephone/emails to communicate with you. This could include requests for you to make or remind you of appointments; to inform you of your results (care will be taken to be sensitive); to gather further clinical information about your consultation; and or direct you to the appropriate services. We may also request information from you via the text service. A record of these texts are kept in your medical records.
Consent to Text Messaging Service
I consent to the receiving and sending of text messages
Note: Please be aware that if you opt out of text messaging from the practice, you will no longer have appointment reminders, appointment cancellations, results, recieve documents i.e. sick notes. The practice is not responsible for the delivery of any letters posted to you via Royal Mail. The practice relies heavily on text communications for speed and delivery of information to our patients.
Consent to Voicemail Service
I consent to the receiving of voicemails from the practice
Consent to receiving emails
I consent to the receiving of emails from the practice

Save and Continue Later

Summary Care Records
Summary Care Records (SCR) are an electronic record of important patient information, created from GP medical records. They can be seen and used by authorised staff in other areas of the health and care system involved in your care.
Consent for Summary Care
*Additional Information includes: significant medical history (past and present) reason for medication Management of long term conditions end of life care information immunisations.
Express consent for medication, allergies adverse reactions and *additional information.
Express consent for medication, allergies and adverse reactions only
Express dissent – patient does NOT want a Summary Care Record and fully understands the risks involved in this decision.
NHS healthcare staff caring for you may not be aware of your current medications, your allergies or adverse reactions to medications you have had, in order to treat you safely in an emergency. Please confirm*
Your Data Matters to the NHS
Information about your health and care helps us to improve your individual care, speed up diagnosis, plan your local services and research new treatments. Your health records contain a type of data called confidential patient information. This data can be used to help with research and planning. You can choose to stop your confidential patient information being used for research and planning. You can also make a choice for someone else like your children under the age of 13.

If you wish to OPT OUT you can complete this online. http://www.nhs.uk/your-nhs-data-matters/manage-your-choice/

Additionally you can OPT OUT by contacting the NHS Digital Contact Centre . Call: 0300 303 5678 Open 9am-5pm Monday – Friday (Excluding Bank Holidays)
Disclosure
Consent to disclose all material regarding healthcare
I agree to disclose all material facts regarding my healthcare to practice clinicians. The practice agrees that we will not share any information about you without your consent. Referrals to social services or specialist services which are made at your request imply consent.
Confidentiality
Confidentiality Consent
Is a fundamental part of HealthCare & crucial to the trust between Doctors & Patients. All staff working in the NHS have Legal, Ethical & Contractual obligations of Confidentiality and must ensure that they act appropriately to protect Patient Information against improper disclosure.
Appointments
Appointments Consent
I agree to attend on time for all appointments. I agree to call the practice to cancel any appointments that I cannot attend. I acknowledge that should I arrive late for an appointment I may be asked to rebook. I accept that the practice has the right to remove me from the list if I do not adhere to this agreement. The practice agrees to notify you if your appointment is being cancelled by the practice and offer you an appropriate alternative.
Emergency Appointments Consent
I acknowledge that the practice operates on an appointment system. I acknowledge that a limited number of emergency appointments may be available each morning for conditions that are regarded by the patient as medical emergencies which have arisen in the previous 48 hours and require immediate medical treatment. I appreciate that this is a triage service and may result in a request that I make a routine appointment. I am aware that sick notes or repeat prescriptions will not be entertained in emergency appointments.
Home Visits
Home Visits Consent
Home visits by a GP or nurse will only take place strictly for our housebound and end of life patients. If a visit is required please request this before 11.00am of the day of the visit. I acknowledge that if I request a home visit the on call doctor will telephone me and advise me of the most appropriate care option. Home visits can only be to your registered address and within our catchment area.
Zero Tolerance
Zero Tolerance Consent
The practice has a zero tolerance for prejudice on the basis of race, creed, gender or sexuality. This applies to patients as well as staff. I accept that the practice can remove me from the list if I behave in an abusive, aggressive, threatening manner to any other patient or to a staff member.
Your Personal Data*
Please note that any personal data you provide will be treated in the strictest of confidence and in full compliance with GDPR legislation. Any identifying information you specify will be held by us for the sole purpose of answering your enquiry. The data will be stored on our server until such time that it is no longer required. If you are happy for us to use and store your data in this way, Please tick the box below. Full details are available in our Privacy Policy.
I consent to Clapham Family Practice storing and using my personal data for the sole purpose of addressing my enquiry.

Save and Continue Later

If you are unable to complete our online registration form, you can download our registration form(s) below. Alternatively, you can attend the practice and collect a registration form from reception. You can hand your completed form in to reception

Adult Patient Registration form – This registration form is for those aged 16 and above.
Child Patient Registration Form – This registration form is for those aged 15 and below.

Do you live within the practice catchment area?

Please use your postcode into the interactive map to ensure that you are living within our boundary.

You are still eligible to register at the practice if you live outside our catchment area. Restrictions apply on the services we can offer:

We do NOT carry out home visits on patients who live outside our catchment area.
Referrals to secondary care (e.g Mental Health Services) and community teams (e.g district nurses/Occupational therapists) may also NOT be possible if you live outside our catchment area.

Medication Name	Dose

Surname	First Name	Date of Birth	Registered at CFP (Y/N)

Medication	Dose

Covid 19 Vaccination Message for Patients January 2021