Online Registration

Please fill in your details and click Submit when complete.

Please only complete this registration form once. If you have previously submitted this form
at any time please do not do so again unless advised by the practice to do so.
Please do not use this form to update your address or other details.

Have you ever registered
with this practice before?
* Are you a Goldsmith student?
* Title:
Please enter your surname or family name
Please enter your first name
  If you don't know your NHS number it's very important that you fill in part 1 and 2 below
* Gender:  
Is your gender identity the same as the
gender you were assigned at birth?
Sexual orientation:  
   
Please fill in your NEW HOME ADDRESS:
Enter your own telephone number. Preferably your mobile number
A confirmation message will be sent to this address.
Confirm your email address
May we contact you using email?    
* May we contact you using SMS text?    
   
 
EMERGENCY CONTACT 
 
Enter a person (full name including surname) we should contact in case of an emergency
Enter a phone number to the emergency contact
Enter your relationship to the emergency contact
Please help us trace your medical records by selecting if you are from UK or from
abroad (Part 1) and then filling in the next section (Part 2)
* Part 1. Select if you are from UK or abroad:
Part 2: Fill in if you come from the UK
(i.e. last address before moving here)





Part 2: Fill in if you come from abroad
You can't register before you arrive in the UK
Have you lived or studied in the UK before?    
Supplementary Questions:
Please select one of the following options: More information...
Complete the following section if you come from another EEA country:
Do not complete this section if you have an EHIC issued by the UK.
Do you have a non-UK EHIC or PRC?   

(e.g. if you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state). Please give your S1 form to the practice staff. More information...
* Signature:
Please draw your unique signature in the box
   
Health Questionnaire
 cm  kg
  * Ethnic origin:  
       
  Need interpreter:     
 
Are you a carer?     Do you have a carer?  
Please tick if you have, or have had, any of the following ILLNESSES:
 
 
 
* Do you SMOKE?
     
    
For smoking cessation advice, please go to Lewisham Stop Smoking services.

How often do you have a drink that contains ALCOHOL?
  A number of alcohol units per week 
NHS Alcohol Unit Calculator  
How many standard alcoholic drinks do you have on a typical day when you are drinking?
How often do you have 6 or more standard drinks on one occasion?
Do you have a Disability or Special Communication Needs?     
Please provide your preferred means of communication:
        
* Please note not all information is currently readily available *
 
Have you ever had a smear test?    
Note: A person with a cervix aged 25-64yrs is eligible for a smear test, regardless of sexual orientation and activity.
 
Have you had HPV VACCINATION?    

At Amersham Vale Practice, we encourage all new patients to be tested for HIV, HEP B and Hep C
Would you like to have a:
HIV test?      Hep B test?      Hep C test?   
If test is reactive (positive) how would you like to be contacted?     
 
 
* NHS Records
There are strict laws and regulations to ensure that your health records are kept confidential and can only be accessed by health professionals directly involved in your care. There is some sharing of information as detailed below. You can opt out of any of these at any time if you wish.
NHS Summary Care Record (SCR) - this is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had.  Having this information stored in one place makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed.
  
 
Organ Donation
Organ donation in England has changed to an 'opt out' system. You still have a choice about whether
or not you wish to become a donor and your faith, beliefs and culture will continue to be respected.
You can record your organ donation decision on the NHS Organ Donor Register.
Tell your family and friends what you have decided
Blood Donation
If you are interested in becoming an blood donor, please click this link
to go to the blood donor registration page.
 
Please read our Privacy Notice.
The information you are submitting will be sent encrypted to the medical practice over the Internet, which still isn't 100% secure.
If you are worried about this you can instead obtain a form from the medical practice that can be filled in and delivered by hand.
* = Compulsory.
 © CampusDoctor Ltd