North Street Medical Care

Romford Site: 274 North Street, Romford, Essex, RM1 4QJ. Tel: 01708 629733
Chadwell Heath Site: Chadwell Heath Health Centre, Ashton Gardens, RM6 6RT

Registration Form

Please complete both the GSM1 form and the North Street Registration medical questionnaire form on the pages below. Registration can be done online, or at any branch, and you will still be free to consult clinicians at either site.

Please review our registration guidelines here before completing the forms for registration.

NS Registration

Patient’s details

Title *
Gender *
Address *
Address
City
County
Post Code

Please help us trace your previous medical records by providing the following information

If you are from abroad

If you are returning from the Armed Forces

If you are registering a child under 5

If you need your doctor to dispense medicines and appliances

(Not all doctors are authorised to dispense medicines)

Signature

*

NHS Organ Donor registration

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply.

NHS Blood Donor registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.
For more information, please ask for the leaflet on joining the NHS Blood Donor Register

HA use only

Patient registered for

To be completed by the GP Practice

I declare to the best of my belief this information is correct
Name

SUPPLEMENTARY QUESTIONS

These questions and the patient declaration are optional and your answers will not affect your entitlement to register or receive services from your GP.
Please tick one of the following boxes:

Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

Do you have a non-UK EHIC or PRC?
If yes, please enter details from your EHIC or PRC below:

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