New Patient Registration

Complete your details below

Register as a new patient

If you would like to register with the practice please use this form. The registration process normally takes 48 hours, if during this time you need medical advice, please visit your previous surgery, contact NHS 111, visit your local pharmacy or for urgent medical advice call 999.

"*" indicates required fields

Step 1 of 4

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Patient's details

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

Yes

NHS number*

How to find your NHS number

Name*

First name Middle name Surname

Previous surname(s)

Date of birth*

DD slash MM slash YYYY

Upload Child Immunisation Data

Please upload a copy of your Child Immunisation Data. This can be found in the Red Book (given at birth). If you are from abroad, please upload any immunisation documents relating to the child. Mandatory for kids registering under the age of 6.

Accepted file types: jpg, gif, png, pdf, Max. file size: 200 MB.

Please declare the following if you do not have the proof (lost childhood immunisation record) or do not remember the dates to input in the above.

I, the legal parent/guardian of the child named on this registration, do hereby declare and confirm that my child is up to date with immunizations as required by the country we have come from or reside in. The aforementioned child has been under my care and supervision since birth. As responsible parents/guardians, we have diligently adhered to the immunisation schedule mandated by the health authorities in our home country. In compliance with the regulations set forth by [Country of Origin]'s health department, we have ensured that my child has received all necessary vaccinations recommended for their age group. These vaccinations include but are not limited to, routine childhood immunisations, booster shots, and any additional vaccinations specified by the relevant health authorities.

Gender*

Male

Female

Other

Town and country of birth*

Your address*

Street Address Address Line 2 City County Post code

Email*

Home phone number

Mobile phone number*

Work phone number

Religion

Marital status

Do you consent to receiving SMS notifications for clinical services?*

Yes

Do you consent to receiving email notifications for clinical services?*

Yes

Preferred contact method

Phone

Text

Post

Ethnicity

Please specify the ethnic group you consider you belong to:*

White British

Black Caribbean

Black Caribbean and White

Indian

Bangladeshi

White Irish

Black American

Black African and White

Pakistani

Other

I do not wish to say

Other

Do you speak English?

Yes

Do you read English?

Yes

Main language

Emergency contact

Name*

First Last

Relationship to you

Their phone number*

Are they your next of kin?*

Yes

Is this person also a patient at the practice?*

Yes

Previous details

Previous address in the UK*

Please include postcode. If you do not have a previous address in the UK, please state N/A.

Name and address of previous GP*

If you do not have a previous GP in the UK, please state N/A.

Arriving from abroad for the first time

Registering with the NHS for the first time in the UK.

Have you recently arrived in the UK for the first time from abroad?*

Yes

Date you came to the UK*

DD slash MM slash YYYY

Are you returning from abroad?

Previously been registered with the NHS in the UK

Have you previously been registered with the NHS in the UK?*

Yes

Date you left the UK*

DD slash MM slash YYYY

Date you returned to the UK*

DD slash MM slash YYYY

Supplementary questions

Are you ordinarily a resident in the UK?*

Yes

European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea

Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?*

Yes

For Patients returning from the Armed Forces

Address before enlisting

Service or personnel number

Enlistment date

DD slash MM slash YYYY

Health questionnaire

Please tell us if you have had any of the following conditions

Asthma

Epilepsy

Cancer

Heart Disease

Thyroid Problems

Stroke

COPD

Diabetes

Depresssion

High Blood Pressure

HIV/Aids

Osteoporosis

When did you have the illness or is it continuing?

Please enter your latest blood pressure reading

Date taken

MM slash DD slash YYYY

Do you have any allergies?*

Yes

Please specify what you are allergic to, what happens and when you had your first reaction*

Are you a carer for a disabled / older person?

Yes

We can refer you to Sutton Carers Centre, who can provide you with support and advice. Would you like us to refer you?

Yes

Lifestyle

Height (cm)*

Weight (kg)*

Smoking Status*

Never Smoked Tobacco

Ex Smoker

Light smoker (1-2 a day)

Moderate smoker (2-8 a day)

Heavy smoker (10+ a day)

How many did you smoke per day?

When did you stop?

Do you drink alcohol?*

Yes

Alcohol Consumption

This is one unit of alcohol

And each one of these is more than one unit

How often do you have a drink containing alcohol?*

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

How many units of alcohol do you drink on a typical day when you are drinking?*

1 - 2

3 - 4

5 - 6

7 - 9

10+

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?*

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Medication

Do you take any regular medication?*

Yes

Please tell us the names of all prescribed medication that you take regularly:

Please make an appointment with the GP to review your prescription.
We require you to get at least a 1 month supply from your previous surgery before requesting from the practice. You should provide us with the information from a previous prescription or bring the empty box in to evidence what you have been issued with in the past whilst we wait for your record to get to the practice.

About your mood

During the last month, have you been bothered by feeling down, depressed or hopeless?*

Yes

During the last month, have you been bothered by little interest or pleasure in doing things?*

Yes

Please feel free to make an appointment with a GP or Nurse Practitioner who can provide support. Alternatively, you can refer yourself for talking therapies.

Adult females only

Please tell us about the number of children you have had, dates and any complications

What type of contraception do you use?

Have you ever had a cervical smear test?*

Yes

When was your last cervical smear?*

PLease use date format DD/MM/YYYY

Was it done at...

A previous GP

A family planning clinic

What was the result of the cervical smear?

Have you had a hysterectomy?

Yes

What type of hysterectomy?

Date of hysterectomy

Do you still have your ovaries?

Yes

Children Only

Is the child this form is about subject to a Child Protection Plan?*

Yes

Electronic Prescriptions

It is the practice's policy to issue all prescriptions electronically. Please tell us which pharmacy you would like to use. You can choose any pharmacy in England, but the closest pharmacies are listed below for your reference.

My chosen pharmacy is:

Please specify name, address and postcode of pharmacy.

Not sure what your closest pharmacy is? Use the NHS Find A Pharmacy tool

Over 75 years old?

The Department of Health has advised that all patients of 75 years and older have a named and accountable GP to oversee their care. Please ask the name of the GP assigned to oversee your care. Please note this does not prevent you from seeing the GP of your choice.

Application for online access to my medical record

I wish to access my medical record online and understand and agree with each statement:*

I have read and understood the Online Services - Important Information page

I will be responsible for the security of the information that I see or download

If I choose to share my information with anyone else, this is at my own risk

I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement

If I see information in my record that it not about me, or is inaccurate I will contact the practice as soon as possible

Signature*

Date

DD slash MM slash YYYY

NHS Organ Donor registration

For more information on organ donation please visit: www.organdonation.nhs.uk

NHS Blood Donor registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323

What happens to my information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.
We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.
To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.
I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.

Information and Confirmations*

I confirm that I am an adult over 18 (or if this form is about a child or young person under 18, I am the legal guardian.)

By providing my mobile number on this form, I agree to receive text messages reminding me of appointments and occasional messages about health campaigns from the practice.

Information for patients arriving from countries outside the EU/EEA
All patients living in our practice area are entitled to free NHS care from a GP. If you have recently arrived from a country outside the EEA, your registration with us does not automatically mean you will be eligible to receive all services the NHS provides free of charge. If you require referral to a hospital, you may be asked to provide proof that you meet the hospital's eligibility criteria for free treatment.

Information sharing with other NHS Organisations
We may share your information with other NHS organisations on a need to know basis (for example, if you are referred to a hospital). We will also make basic information about you (demographic information, medication and allergies) available to other NHS organisations. Anonymised data will be uploaded via the General Practice Extraction Scheme. Please see our web site for more information and write to us if you would like to opt out of either or both schemes.

Signature*

Date

DD slash MM slash YYYY

To complete your registration please upload proof of identify, this should include Photographic ID and proof of address*

Drop files here or

Max. file size: 200 MB.

Name

This field is for validation purposes and should be left unchanged.

SURGERY ENQURIES

020 8689 7800 – lines open 8.30am
swlicb.brigstockfamilypractice@nhs.net
Brigstock Family Practice
83 Brigstock Road
Thornton Heath
Surrey CR7 7JH

SURGERY HOURS

Monday – Friday*	08:00 – 20:00
Saturday**	09:00 – 17:00

*Surgery reception closed between 1pm-2pm every Weds for training

**North Croydon GP Enhanced Access & Reception Service only

REGISTER AS PATIENT

PRACTICE BROCHURE

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HOW WAS YOUR EXPERIENCE WITH US?

USEFUL CONTACTS

General enquires & appointments (from 8.30am):
020 8689 7800

Brigstock Skin and Laser Centre
0330 555 6060

NHS Croydon:
020 8274 6000

Patient advice and liaison service (PALS):
020 8274 6333

Public Health Department:
020 8274 6239

Croydon Intermediate Ear Nose and Throat service
020 8683 6734

NHS Out of hours service
111

Data Protection Officer
Umar Sabat | Email: dpo.swl@nhs.net