*REGISTRATION* – The Vauxhall Surgery

First Name *

Middle Name

Last Name *

Date of Birth *//

Gender *

Male
Female

Ethnicity *

Main Spoken Language *

Do you require an Interpreter? *

Town and Country of birth *

Home address *

Address in the UK

Post Code *

You can register with us even if you live outside our practice area! To be eligible for home visits, you must live within the practice catchment area

Previous Home Address *

NHS Number

if known

Mobile Phone *

Home Phone

Work Phone

Email *

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

Previous GP Surgery *

DATE of entry into the UK *

HIV Screening *

HIV Screening Accepted
HIV Screening Declined

All new patients are eligible for free a HIV test which can be done in surgery by our Healthcare Assistant via a blood test

Current Smoking Status *

Current Smoker
Ex-Smoker
Never Smoked Tobacco

Alcohol Consumption per week (Units)

Do you have private insurance? *

We are an NHS GP Practice. You do NOT need private insurance to register with our practice or use our services.

Nominated Pharmacy *

Osbon Pharmacy - 143 Lambeth Walk - SE11 6EE
Tesco Pharmacy - Kennington Lane - SE11 5QU
Hills Pharmacy - 99 Kennington Lane - SE11 4HQ
Lambeth Pharmacy - 76 Kennington Road, SE11 6NL
Medimex Chemist - 222 Kennington Park Road - SE11 4DA
Vitelow Pharmacy - 26 Clapham Road - SW9 0JG
Other [please include name and postcode]

The Vauxhall Surgery can send your medication electronically to a nominated pharmacy of your choice to be ready for collection

Nominated Pharmacy

Next of Kin / Emergency Contact

Next of Kin/Emergency Contact *

First

Last

Next of Kin Gender *

Male
Female

Next of Kin Contact Number *

Relationship to Patient *

Summary Care Record - You have the choice of what information you would like to share and with whom. *ONLY* Authorised healthcare staff can view your SCR with your permission. The information shared will solely be used for the benefit of your care. *

Summary Care Records are an electronic record of important patient information, created from GP medical records. If you are registered with a GP practice in England, you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past. Information about your healthcare may not be routinely shared across different healthcare organisations and systems. You may need to be treated by health and care professionals who do not know your medical history. Essential details about your healthcare can be difficult to remember, particularly when you are unwell or have complex care needs. Having a Summary Care Record can help by providing healthcare staff treating you with vital information from your health record. This will help the staff involved in your care make better and safer decisions about how best to treat you.

Consent to receive results via text message

If you had a recent test such as a blood test or XRAY, our doctors may send you a text message to inform you of the outcome.

Patient Signature *

Please write your name or parent/carer for under 16s

Confirmation *

I agree to switch my registered GP practice.

By confirming, you are consenting to leave your current NHS GP practice. You are free to change your NHS GP practice at any time.

Registration

The Vauxhall surgery, london

The personal information we keep about you is to help us provide health or social care or treatment, under the Data Protection Act (DPA) 2018.

Anyone can register with us

Next of Kin / Emergency Contact