Locate Us:
2nd Floor, Akerman Health Centre
60 Patmos Road, London, SW9 6AF
Tel. 020 3582 0000
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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:
* Ethnicity:
Asian or Asian British
Bangladesh
Indian
Pakistani
Asian - Other
Black or Black British
African
Caribbean
Black - Other
Chinese or other ethnic group
Chinese
Other
Latin
Latin American
Latin - Other
Mixed Background
White and Asian
White and Black African
White and Black Caribbean
Mixed - Other
White
British
Irish
White - Other
* Main Language Spoken:
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:

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.