Locate Us:
2nd Floor, Akerman Health Centre
60 Patmos Road, London, SW9 6AF
Tel. 020 3049 6500
Fax. 020 3049 6515
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Register With The Practice

Please take a few minutes to fill in and return this questionnaire. Please answer all questions and tick the boxes where indicated.

* Gender: Male Female
* Surname:
* First Names:
Other Names:
Previous Surname(s):
* D.O.B:
* Place Of Birth:
NHS Number:
* Current Address:
* Postcode:
* Telephone No:
Mobile No:
* Email:

* Previous Surgery Name:
* Previous Patient Address:
OR
* If you have never been registered at a doctor's surgery in the UK - Date of arrival into the UK:

Akerman Medical Practice currently offers free HIV testing for all new patients. If you would like a free HIV test, tick here and a member of the practice will get back to you.

I am the above named patient - I confirm that the information provided is correct to the best of my knowledge.

OR

I am registering on behalf of the above named patient - I confirm that the information provided is correct to the best of my knowledge.