High Road Surgery, Wood Green
-Registration form (please answer all questions)
3. First name:
4. Previous Surname:
6. NHS No.:
(if you do not have a NHS number, enter 1122112211)
11. Your email address-
12. Previous GP details-
13. Are you born in the UK?
13a. City and borough of birth.
13b. Country of birth. Date you first came to the uk.
14. Marital status:
15. Ethnicity (please write your ethnicity):
16. Next of kin- Name:
17. Do you permit your next of kin to discuss your medical concerns?:
cigs a day till
-cig per day
19. Alcohol intake:
Do not drink
-unit per week
20. Drug usage:
23. Past medical history(ex:asthma/cancer):
24. Family history of medical conditions:
25. Female patients:
Last smear test date:
26. How did you find us-
Registration of childern under the age of 16 (Provide Birth Certificate + Immunisation History)
29. Subject to child protection:
30. Is this child in a care home or foster care?
How often do you have a drink containing alcohol?
Monthly or less
2 - 4 times per month
2 - 3 times per week
4+ times per week
How many units of alcohol do you drink on a typical day when you are drinking?
1 - 2
3 - 4
5 - 6
7 - 9
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?
Less than monthly
Daily or almost daily
Download the form and email to
. Attach photo ID(eg:passport, driving, licence or identity card) and proof of address(utility bill, bank statement, tenancy agreement, driving licence). If it is for a child under 16 attach the birth certificate and immunisation history.