Essex House Surgery

Station Road, Barnes , London, SW13 0LW

Current time is 14:06 - We're open

Telephone: 020 8876 1033

swlccg.essexhouseenquiries@nhs.net

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You are here:
Home
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New Patient Registration

You are here:
Home
/
New Patient Registration

New Patient Registration

Please ensure you fill this form out in full. If the form does not have enough information, we can not register you at the practice.

Please select below*
- Mr
- Mrs
- Miss
- Ms
Please provide your full name*
Please provide any previous forenames or surnames that may help us find your NHS England medical records
Date of birth*
Date Format: DD slash MM slash YYYY
Place of birth (please note 'London' is not accepted.)*
Current address*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Please tell us your previous registered address that relates to when you were last registered at a GP practice. This will help us obtain your medical records.
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Please tell us your previous GP practice address and name. If you have registered with a practice in England, we will need this to find your medical records.
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Please provide your NHS number, if you do not know this your previous GP or dentist can give this information to you.
If you have not previously registered with NHS England please tell us the date in which you entered the U.K
Date Format: MM slash DD slash YYYY
Phone
Email
Next of Kin (NOK) details
Please provide a contact number, the relation to you and name for your next of kin. Should the practice be unable to reach you, or there is an emergency within your appointment, this person will be contacted.
Is there anyone registered at this practice we should 'link' you to? I.e. a relative
If you are a carer, or you have a carer please let us know their name and contact information below.
Please tell us your ethnicity*
Please tell us your preferred language ( if not English)
Smoking status*
If you are a current smoker, would you like help to stop?
How many units of alcohol do you drink per week?*
1 unit of alcohol is the equivalent to half a beer/larger, a small glass of wine or a pub measure of spirit (25ml). Please give us the number in total units per week. i.e. 5 pints per week is equal to 10 units.
Do you exercise regularly?*
Please input your current height*
What is your current approximate weight?*
Are you allergic to any drugs? If 'yes' please specify
Are you taking any regular medication? If 'yes' please list them below and the reason you have been advised to take them.
Is there any further medical information you would like to tell us? For example if you are currently pregnant.
Electronic Prescriptions (EPS)
You can now have your prescription sent electronically direct to your chosen pharmacy. Please let us know the pharmacy name and address you wish to collect your medication from
Signature
Email
This field is for validation purposes and should be left unchanged.

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Opening Times

Monday
08:00 until 12:00
13:00 until 18:30
Tuesday
08:00 until 12:00
13:00 until 18:30
Wednesday
08:00 until 12:00
13:00 until 18:30
Thursday
08:00 until 12:00
13:00 until 18:30
Friday
08:00 until 12:00
13:00 until 18:00
Saturday
CLOSED
Sunday
CLOSED

Useful Links

Asthma UK