It is your responsibility to keep us updated with any changes to your telephone number, email & postal address. We may contact you with appointment details, test results or health campaigns
These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.
Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision.
Anybody in England can register with a GP practice and receive free medical care from that practice. However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK. Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges. More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice.
You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment. The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.
Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.
If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.
If yes, please enter details from your EHIC or PRC below
How will your EHIC/PRC/S1 data be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process. Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.
If yes please provide the details below. Only add carer’s details if they give their consent to have these details stored on your medical record
Immunisations play a crucial role in keeping children healthy. We want to ensure your child is up to date with their immunisations according to the UK schedule. Please can you bring in your child’s red book or immunisation record and give to the reception team to take a copy.
Please answer the following questions which are validated as screening tools for alcohol use
Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent
We are committed to improving the services we provide. The Patient Participation Group is a mechanism for us to gain valuable feedback from our patients about their experiences, views and ideas for improving our services.
We may need to share your medical information with other organisations involved in the delivery of your care e.g. Hospital colleagues or District Nursing. We will not share identifiable information with anyone that isn’t involved in your care unless legally required to. If you wish to change your mind at any time, please contact us
Summary Care Records (SCR) are an electronic record of important patient information, created from GP medical records. It can be seen and used by authorised staff in other areas of the health and care system involved in the patient’s direct care. It includes the following basic information: Medicines you are taking , allergies you suffer from and any bad reactions to medicines. It also includes your name, address, date of birth and unique NHS Number which helps to identify you correctly.
If you wish to Opt Out of SCR please download the SCR opt out form on the registration page and return to us
Patient online has been designed to support our patients by providing access to online services which include things like, booking and cancelling appointments, ordering your repeat prescription and viewing certain parts of your medical record. To gain access to your online account the section below must be completed. Our practice policy ensures that all applications for online registration will be reviewed and we aim to inform you within 2 weeks whether this has been approved
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
Blackfriars Medical Practice
45 Colombo Street, London, SE1 8EE.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.