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:

* Are you living in the UK on a properly settled basis for the time being?
(Nationals of countries outside of the European Economic Area must also have the status of 'Indefinite Leave To Remain' in the UK)
Yes No
a) I understand that I may need to pay for NHS treatment outside of the GP practice
b) I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes, for example, an EHIC, or payment of the Immigration Health Charge ("the Surcharge"), when accompanied by a valid visa. I can provide documents to support this when requested
c) I do not know my chargeable status

I am an EEA citizen, and I hold a European Health Insurance Card (EHIC) or Provisional Replacement Certificate (PRC).
Country Code:
Name:
Given Names:
Date Of Birth:
Personal Identification Number:
Identification Number Of The Institution:
Identification Number Of The Card:
Expiry Date:
PRC Valid From:
PRC Valid Until:
I am an overseas citizen, and I hold an S1 form.

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.