New patient registration

Contact details


Practices part of First Care Group Practice

Heathrow Medical Centre
Telephone: 020 8754 1555

Shakespeare Health Centre
Telephone: 0203 794 3119

The Pine Medical Centre
Telephone: 0208 432 8569
About this form

Fields marked with a asterisk (*) are compulsory.
Please note that we will not respond to any medical information or questions received through the survey.

The information you supply us will be used lawfully, in accordance with GDPR Regulations. GDPR gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly.

Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of registration.

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.

Please select your practice


Your Details





Next of kin


Medical details


 


Language support


Carers

Do you look after a sick, disabled, frail relative or friend without payment? Is there a child or young person in the family who helps to provide care or support to another family member?

Approximately 10% of the current population are carers.

In order to help us update our Carers Register please spend a few minutes of your time completing this information.


NHS organ donor registration

For more information, please visit www.uktransplant.org.uk

I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death and confirm consent to organ donation. Please tick if you would like to join:


NHS blood donor registration

For more information, please visit www.blood.co.uk

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood. Please tick:


Other details


How did you hear about us?*


Do you agree to be contacted regarding this matter?:*

 
Contact details


Practices part of First Care Group Practice

Heathrow Medical Centre
Telephone: 020 8754 1555

Shakespeare Health Centre
Telephone: 0203 794 3119

The Pine Medical Centre
Telephone: 0208 432 8569
About this form

Fields marked with a asterisk (*) are compulsory.
Please note that we will not respond to any medical information or questions received through the survey.

The information you supply us will be used lawfully, in accordance with GDPR Regulations. GDPR gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly.

Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of registration.

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.