New Patient Registration Form


Please note, we have now temporarily relocated to the following address:
South Lambeth Road Practice
Akerman Health Centre
First Floor
60 Patmos Road

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Before you begin, please ensure you have the following information handy:

  • Your previous GP's details (if applicable)
  • If you are from abroad, we will need the date you first entered the country
  • You do not need to provide ID but if you upload this in the section where it is asked, we will be able to make an online account that will allow you to view your medical record and request medications/other services via the Patient Access app.
Your Details

Please note that this person will be used as an emergency contact if we cannot reach you in an emergency

Child registration information

All children  registered with the Deerbrook surgery will be eligible for baby checks and immunisations

Ethnicity, Religion & Communication
Previous Details
Please include postcode
please ensure this is provided accurately as it may affect your registration if incorrect information is given
If you are from abroad
Please use this date format: DD/MM/YYYY
If you are returning from abroad

Previously been registered with the NHS in the UK

Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Were you ever registered with an Armed Forces GP

Footnote: 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

Supplementary Questions

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 at reception. Alternatively for more information go to

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.

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.

A parent/guardian should complete the form on behalf of a child under 16.

European Economic Area (EEA) Country

For a list of EEA countries visit:

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.

Please enter the details from your EHIC or PRC below.

S1 Form

Please give your S1 form to the practice staff.

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.

Main carer for a person

A main carer is defined as the following:

  • someone who is in receipt of carers' allowance
  • someone who looks after another person that has a significant impairment that would mean they couldn't normally look after themselves
  • a parent who has a child with a substantial disability

After registration is complete, please advise the practice if there are any elements of your medical problems that you would not like us to discuss with them

Immunisation History
Please include dates if you know these. You can upload any record you have of this at the end of the registration process
Medical History
Please include dates.
Please include dates.
Please include dates.

You have the opportunity to see any doctor at the practice. This is to inform you that your named allocated doctor is Dr Imtiaz Ahmad

NHS Blood and Organ Donation

NHS Blood and Transplant services need you and especially need donors from BAME backgrounds, please click the icon to visit their web page.

The law on organ donation changed in May 2020, please click the link to understand how the "opt out" system affects you


All new patients are offered an HIV test. Please let our healthcare assistant know if you'd like to take up this offer when you come in for a new patient check


Body Mass Index


Please click here for information and help on how to give up

Your Personal Alcohol Consumption

Audit Score Result

you have an AUDIT-C score of

An AUDIT-C score above 3 for women (and above 4 for men) means you should consider reviewing the way you drink alcohol

Further help including finding local services to help with alcohol consumption can be found here.

Identification Upload

As you are registering someone under 16, there is no need for any ID documents to be uploaded. However, if you want to use Online services for this account eg to book appointments, request medications or view the medical record online or via an app, please click yes in the box below and we may require you to upload some documents below or show them to reception:

As you are registering a newborn, there is no need for any ID documents to be uploaded. We will automatically make an online account for the baby, eg to book appointments, request medications or view the medical record online and via an app. If you don't already use Patient Access, please click here to get yourself registered.

Once you're registered on Patient Access, you can link yourself to your child's account by clicking on this guide. Please let us know if you need any help.


In order to be able to use an online account to view your child's record and request medications/book appointments, you need to ensure you are already set up on Patient Access. If you're not set up, please click hereto set this up for yourself. If you are already set up, we can Link you to your child's record by setting you up as a proxy. In order to do this, we will need some ID relating to the child to be uploaded below.Once you've done this below, the child will appear in your account settings after a few days. Click this guide showing how to link them in Patient Access.

ID upload for online services

To enable you to have an online account to iew results and request medication via the Patient Access app, we need one form of Acceptable ID. You can still register without this, however we cannot make an online account until we have seen identification. We will not store these documents and we will securely delete / destroy them after our initial verification. You can also upload any reports like immunisations or records from abroad that you wish for us to upload to your record. If you would like to have an online account but do not wish To upload identification, you can show any form of the above acceptable ID to reception and then an account can be made for you.

Acceptable Identification: Photo Driving License, Passport, Residency card (for children a birth certificate is acceptable)

Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx

Summary Care Record and Information Handling

Your information will be shared between your GP practice, our local hospital(s) and Out Of Hours service. This will enable your GP surgery to access results and any visits you have at the hospital quickly and efficiently, but it also means that if you have an emergency and contact the Out Of Hours service or visit A&E they will have access to your current medications as well as allergies and are better able to treat you.

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you. We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols. No information is ever allowed to be used for marketing purposes.To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts, the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

By signing below, I agree to the following:

  • I declare that the information provided is correct to the best of my knowledge.
  • I understand and agree that the practice and/or the local health authority will contact me via text message or email for matters directly related to my healthcare.
  • I understand that if my postcode is outside the catchment area of the practice, I will still receive the full services of an NHS General Practice but agree that in the unlikely event of needing it, I will not be eligible for home visits from the practice.
  • I give my express consent to provide information to the summary care record for medication, allergies and additional information to be used in an emergency or if I am seriously ill in a hospital. I understand that I can inform the practice should I change my mind about this.

Please sign either using your mouse/trackpad or a finger if you are on a touchscreen device

Child signature

As you're making an online account for a child over 12 years old, we need them to agree to this

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.


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