For us to be able to correctly process your registration it is important that the whole form is completed.
Click here to download a copy of the registration form to fill in and bring in to reception. Alternatively please complete the form below and submit online.
Website details: www.transplant.org.uk or contact them on 0300 123 23 23
For female patients only:
Please list any serious illnesses or operations you have had in the past and the date
Do you, your parents, grandparents or siblings have a history of any of the following:
We would advise all patients to give up smoking; it is harmful to your health.
Website address: www.nhs.uk/smokefree or call 0300 123 1044
The following questions relate to your ethnic origin and this information is used only for research purposes. It would help us if you kindly agreed to provide this information. All information remains strictly confidential and is only available to authorised NHS staff. This information relates to the patient stated in the previous sections.
Please provide the following if the preceding information relates to a child aged 0 to 15 years of age.
Please provide information regarding this child's immunisation record
Your Summary Care Record contains important information about any medicines you are taking, any allergies you suffer from and any bad reactions to medicines that you have previously experienced. Allowing authorised healthcare staff to have access to this information will improve decision making by doctors and other healthcare professionals and has prevented mistakes being made when patients are being cared for in an emergency or when their GP practice is closed. Your Summary Care Record also includes your name, address, date of birth and your unique NHS Number to help identify you correctly.
As a patient of this practice you are automatically enrolled, however if you choose to opt out of having a Summary Care Record and do not want a SCR, you need to let your GP practice know by filling in and returning an opt-out form. Opt-out forms are available at http://systems.hscic.gov.uk/scr/staff/aboutscr/comms/pip/optout.pdf or from the GP practice.
Further information can be found at: http://www.nhscarerecords.nhs.uk/
The people caring for you need to share some of your information with others that are also supporting you. This could include GPs, hospital based specialists, nurses and health visitors.
To enable this information sharing to happen more quickly and to improve the care you receive, a new process has been put in place in Lambeth called the Local Care Record.
Through existing computer systems, this will join up care records held on your GP practice with the three main local hospital organisations: Guy's and St Thomas', King's College Hospital and South London and Maudsley NHS Foundation Trusts.
Information is only shared when it is needed to make your care and treatment safer, easier and faster and only with those people directly involved in your care. This could include allowing a hospital doctor to see the medication that a GP has prescribed for you when you go into hospital or allowing a GP to see what care, tests or treatment you received while in hospital.
As a patient of this practice you are automatically enrolled, however if you choose to opt out of the Local Care Record and do not want a LCR, you need to let your GP practice know by filling in and returning an opt-out form. Opt out forms are available via reception or by downloading from: http://slicare.org/localcarerecord
Please note that you may not see the doctor of your choice when given an emergency appointment.
Only answer the following questions if the answer above is Never (0), Less than monthly (1) or Monthly (2). Stop here if the answer is Weekly (3) or Daily (4).
If score is 3 or 4 on the first question continue with the following questions
Please remember to make an appointment for your new patient health check
Our practice is working with Public Health England to offer patients who are eligible a simple blood test to see if they have a condition called Latent Tuberculosis. You would not have any symptoms of this condition so a simple blood test can check if you have it. If the blood test result is positive you can then be referred for treatment before you develop symptoms.
Please complete the following checklist to see if you are eligible .
If you have answered yes to all of the above you will be contacted by the practice and invited in for an appointment to have the blood test.
Information submitted through secure forms is used only for the purposes of processing your request. We may
be in touch with you in relation to the information submitted.
All Information submitted through secure forms is secured with a private key and is accessed over a secure
connection by nominated staff. We have a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
I consent to my information being used for the purposes described above and wish to submit this online form to
Streatham Common Practice
St Andrew's Church Room, Guildersfield Road, London, SW16 5LS.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.