Wakemans Hill Surgery

1 Wakemans Hill Avenue. Colindale. London NW9 0TA

Telephone: 0208 205 2336

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Family Doctor Service Registration

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Patient details

Title*

Date of Birth*

DD slash MM slash YYYY

Gender*

NHS Number

First Names*

Birth Town*

Surname*

Birth Country*

Current Address and Postcode*

Telephone*

Mobile*

Email Address*

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

Have you previously been registered with an NHS GP in UK?*

Yes

No

Name of Previous GP*

Address of Previous GP*

Your Previous Address

This is usually the address when you were last registered with a GP

Your first UK address*

Date you first came to UK

DD slash MM slash YYYY

Are you returning from the Armed Forces?*

Yes

No

Please indicate if you have ever served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas*

Regular

Reservist

Family Member

Address and Postcode before enlisting*

Service or Personnel Number*

Enlistment date*

If you are registering a child under 5

Child Health Surveillance

I wish the child above to be registered with the named doctor for Child Health Surveillance

If you need a doctor to dispense medicines and appliances

Nearest Chemist

I live more than 1 mile in a straight line from the nearest chemist

Chemist Difficulty

I would have serious difficulty in getting them from a chemist

Signatures

Signatures*

Patient's signature

Signature on behalf of patient

Consent

I agree for the Practice to contact me using the details provided above.

Electronic Signature (Type your full name here)*

By completing the section above, I hereby sign this form electronically

NHS Organ Donor Registration

Would you like to join the NHS Organ Donor Register?*

Yes

No

Already on it

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.*

Any of my organs and tissue

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

NHS Blood Donor Registration

Would you like to join the NHS Blood Donor Register?*

Yes

No

Already on it

Tick here if you have given blood in the last 3 years

I have given blood in the last 3 years

My preferred address for donation is:

Comments

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87470

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Prescriptions

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Patient Participation Group

Friends & Family Test

Opening Times

Monday
08:00 to 18:30
Tuesday
08:00 to 18:30
Wednesday
08:00 to 18:30
Thursday
08:00 to 18:30
Friday
08:00 to 18:30
Saturday
CLOSED
Sunday
CLOSED

Useful Links

NHS Choices

NHS 111

Patient UK

Cost of Living Support

NHS A-Z Conditions

Find Local Services

Live Well

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Phone

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56472

Friends & Family Test

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We would like you to think about your recent experiences of our service.

Thinking about your recent visit, overall, how was your experience of our service?*

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Please can you tell us why you gave your answer?

Comments

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36147

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