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Repeat Prescription Request Form
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Asthma Review Form
Blood Pressure Review Form
Breathlessness Review Form
Epilepsy Review Form
Male Urinary Tract (IPSS) Review Form
Mental Health Review (PHQ-9) Form
Smoking Review Form
Travel Risk Assessment Form
Register with us as a New Patient
Further Help about how to Register with a GP
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Long Term Conditions
NHS Health Check aged 40 – 74
Travel Clinic & Holiday Vaccinations – this service is currently unavailable.
Flu Vaccination clinics
Enhanced Access Service: Weekday Evening and Saturday Appointments.
Online Services
Practice Services
Advocacy Service
Cervical Screening
District Nurses and Adult Social Care
Dementia Services
Diabetes Services
Hepatitis B Immunisation
Housebound & Older People
Home Visits
Interpreting Service
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Autism
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British Deaf Association
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Disability Rights UK
Deaf or Hard of Hearing
Get Active with a Disability
How to Care for a Disabled Child
Learning Disability
National Autistic Society
SCOPE – Equality for Disabled People
Vision Impairment
General Health Advice
Antibiotic Awareness
Diarrhoea and Vomiting – Do’s and Don’ts
Healthcare Associated Infection
Managing an Infection
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Age UK
Are you a Carer?
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Carers UK
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#hellomynameis
End of life care
Together for short Lives
Family Lives
Humankind
Health Unlocked
MS Society
Orchid – Fighting Male Cancer
Penile Cancer
Same You
Shelter – England
Together for Short Lives
The Pavement
The Brain Tumour Charity
Services for Carers
Health & Wellbeing
More about Sprains and Strains
Food Allergy
Vitamin B12 or folate deficiency anaemia
Testicular Cancer – Check Yourself
Help & Support in your Area
Housing Applications
Lewisham Council
Mindkit
Know Who to Turn to for Your Healthcare
Accident & Emergency
Dentist
Hospitals
NHS Out of Hours Services
Optician
Pharmacist
Lifestyle Changes
Healthy Eating
Physical Activity – The Single best Medicine
#2077 (no title)
Weight Management
Stop Smoking Service
Long Term Conditions
Asthma
Breast Cancer (female)
Chronic Obstructive Pulmonary Disease (COPD)
Coronary Heart Disease
Dementia
Dementia with Lewy bodies
Diabetes
Epilepsy
High Blood Pressure (Hypertension)
Osteoarthritis
Prostate Cancer
Menopause
Mental Wellbeing
Depression
Doc Ready
Dealing with a Mental Health Crisis or Emergency
Healthtalk
Lifelink
Making Space
Mind – for better Mental Health
Mental Health Helplines
Mental Health – General Advice
Mental Health Issues if you’re Gay, Lesbian or Bisexual
Rethink Mental Illness
Samaritans
SANE
Time to Change
Order a Repeat Prescription
Antibiotic Use
Electronic Prescriptions Service
Over the Counter Medicine
Wasted Medications
Pregnancy & Baby
Am I Pregnant?
CRY-SIS Helpline
Maternity Services Locations
Postnatal Depression
Smoking affects your Unborn Baby
Start 4 Life
Sexual Health & Sexuality
Contraceptive Advice & Sexual Health
Your Contraception Guide
Free Condoms
Gender Dysphoria
LGBT Foundation
Maria Stopes UK
Sexual and reproductive health in Lewisham
Sexually Transmitted Disease
Preventative Medicine
Flu Vaccination
Annual Health Check
HPV Vaccination
Pneumococcal vaccine
Screening Services
Shingles
Young People
Kooth
The Mix
Youth First
Young Minds
Lewisham Speaking Up
Home
About Us
Baby Friendly
Contact
Contact Telephone Numbers
Location
Opening Hours
What to do when we are closed
Patient Opinion
Signing Up For Patient Participation Group
Subject Access Request (SAR)
Send a Message
Would you recommend our service to friends and family?
Making the Most of your Practice
Our Mission and Vision
Our Team
Allied Nurses
Doctors
Physician Associate
Nurses
Practice Administration Team
Patient Participation Group
Practice Policies
At the Practice
Chaperones
Clinical Governance
Clinical Research
Consent Protocol
Duty of Candour
Disability Access
Equality and Diversity
Infection Control Statement
Named GP Policy
Non-Smoking Premises
Quality Assurance
Removal of Patients from our list
Shared Decision Making
Safeguarding Children
Unacceptable Actions Policy
Data
Care Data
Data Choices
Freedom of Information
General Practice Extraction Service (GPES)
Your NHS Data Matters
Patient Record
Accessing your Record
Access for Others
Subject Access Requests (SAR)
London Care Record
The National Care Record Service (NCRS)
Data Sharing Preferences
Choose if data from your Health Records is shared for Research and Planning
Multi-Disciplinary Teams
Organ Donation
Sharing your Information with Others
Summary Care Record
How we use your Data
Confidentiality
Privacy Policy
Online Access
Proxy Access
Patient Rights
Complaints, Compliments & Suggestions
Entitlement to NHS Treatment
Patient Advice and Liaison Service (PALS)
NHS Patient Rights
Your Rights and Responsibilities
Website Policies
Accessibility
Cookie Policy (UK)
Copyright
Disclaimer
Regulations & Governance
Care Quality Commission (CQC)
GP Earnings
The NHS Constitution for England
Teenage Friendly
Administration
Get a Sick or Fit Note
Repeat Prescription Request Form
Health Review Forms
Alcohol Consumption Review Form
Asthma Review Form
Blood Pressure Review Form
Breathlessness Review Form
Epilepsy Review Form
Male Urinary Tract (IPSS) Review Form
Mental Health Review (PHQ-9) Form
Smoking Review Form
Travel Risk Assessment Form
Register with us as a New Patient
Further Help about how to Register with a GP
Registration Policy
Temporary Services
Update your Personal Details Forms
Change of Contact Details Form
Register as a Carer Form
Register for Online Services Form
Communication Consent Form
Appointments, Tests & Referrals
Appointments
Book an Appointment
Cancel an Appointment
Enhanced Access Service
Get Immediate Help for Minor Injuries
Help with your GP Appointment
Telephone consultations
Referral for Further Care
NHS e-Referral Tracking
Referral to Hospital by your GP
See a Doctor or Healthcare Professional
Tests & Investigations
Access your Test Results
Blood Tests
Other Common Tests
Urine Tests
X-Rays & Scans
Who Do I See?
Clinics & Services
Clinics
Antenatal Care
Child Health Checks
Clinics we provide
Long Term Conditions
NHS Health Check aged 40 – 74
Travel Clinic & Holiday Vaccinations – this service is currently unavailable.
Flu Vaccination clinics
Enhanced Access Service: Weekday Evening and Saturday Appointments.
Online Services
Practice Services
Advocacy Service
Cervical Screening
District Nurses and Adult Social Care
Dementia Services
Diabetes Services
Hepatitis B Immunisation
Housebound & Older People
Home Visits
Interpreting Service
NHS Services
New Medicine Service (NMS)
Non NHS Services – Chargeable
Patient Transport Service
Texting Service
Advice & Support
Your Health
Alcohol & Drug Services
Blood donation
MesotheliomaHope
Children’s Health
Change4Life
Children and Young People’s Services
Childline
ERIC – The Children’s Bowl & Bladder Charity
Triple P – Positive Parenting Programme
Disability
Autism
Action on Hearing Loss
British Deaf Association
Contact – for Families with Disabled Children
Disability Rights UK
Deaf or Hard of Hearing
Get Active with a Disability
How to Care for a Disabled Child
Learning Disability
National Autistic Society
SCOPE – Equality for Disabled People
Vision Impairment
General Health Advice
Antibiotic Awareness
Diarrhoea and Vomiting – Do’s and Don’ts
Healthcare Associated Infection
Managing an Infection
Help & Support
Care & Support
Age UK
Are you a Carer?
At a Loss
Bereavement
Cancer Support Services
Carers UK
End of Life Care
#hellomynameis
End of life care
Together for short Lives
Family Lives
Humankind
Health Unlocked
MS Society
Orchid – Fighting Male Cancer
Penile Cancer
Same You
Shelter – England
Together for Short Lives
The Pavement
The Brain Tumour Charity
Services for Carers
Health & Wellbeing
More about Sprains and Strains
Food Allergy
Vitamin B12 or folate deficiency anaemia
Testicular Cancer – Check Yourself
Help & Support in your Area
Housing Applications
Lewisham Council
Mindkit
Know Who to Turn to for Your Healthcare
Accident & Emergency
Dentist
Hospitals
NHS Out of Hours Services
Optician
Pharmacist
Lifestyle Changes
Healthy Eating
Physical Activity – The Single best Medicine
#2077 (no title)
Weight Management
Stop Smoking Service
Long Term Conditions
Asthma
Breast Cancer (female)
Chronic Obstructive Pulmonary Disease (COPD)
Coronary Heart Disease
Dementia
Dementia with Lewy bodies
Diabetes
Epilepsy
High Blood Pressure (Hypertension)
Osteoarthritis
Prostate Cancer
Menopause
Mental Wellbeing
Depression
Doc Ready
Dealing with a Mental Health Crisis or Emergency
Healthtalk
Lifelink
Making Space
Mind – for better Mental Health
Mental Health Helplines
Mental Health – General Advice
Mental Health Issues if you’re Gay, Lesbian or Bisexual
Rethink Mental Illness
Samaritans
SANE
Time to Change
Order a Repeat Prescription
Antibiotic Use
Electronic Prescriptions Service
Over the Counter Medicine
Wasted Medications
Pregnancy & Baby
Am I Pregnant?
CRY-SIS Helpline
Maternity Services Locations
Postnatal Depression
Smoking affects your Unborn Baby
Start 4 Life
Sexual Health & Sexuality
Contraceptive Advice & Sexual Health
Your Contraception Guide
Free Condoms
Gender Dysphoria
LGBT Foundation
Maria Stopes UK
Sexual and reproductive health in Lewisham
Sexually Transmitted Disease
Preventative Medicine
Flu Vaccination
Annual Health Check
HPV Vaccination
Pneumococcal vaccine
Screening Services
Shingles
Young People
Kooth
The Mix
Youth First
Young Minds
Lewisham Speaking Up
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Contact us online
Travel Risk Assessment Form
Travel Risk Assessment
First Name
*
Last Name
*
Email
*
Enter Email
Confirm Email
*
Confirm Email
Date of birth
*
Please use format day/month/year e.g. 12/05/1979
Phone Number
*
Gender
*
Male
Female
Date of Departure
*
Please use format day/month/year e.g. 12/05/2019
Date of Return
*
Please use format day/month/year e.g. 12/05/2019
Please give details of country to be visited, length of stay, and how remote you’ll be from medical help
*
Type of trip
*
Business
Pleasure
Other
Holiday type
*
Package
Self organised
Backpacking
Camping
Cruise ship
Trekking
Accommodation
*
Hotel
Relatives / family home
Other
Travelling
*
Alone
With family / friend
In a group
Staying in area which is
*
Urban
Rural
Altitude
Planned activities
*
Safari
Adventure
Other
Do you have any recent or past medical history of note? (including diabetes, heart or lung conditions)
*
List any current or repeat medications
*
Do you have any allergies for example to eggs, antibiotics, nuts?
*
Have you ever had a serious reaction to a vaccine given to you before?
*
Yes
No
Don’t Know
Does having an injection make you feel faint?
*
Yes
No
Don’t Know
Do you or any close family members have epilepsy?
*
Yes
No
Don’t Know
Do you have any history or mental illness including depression or anxiety?
*
Yes
No
Don’t Know
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
*
Yes
No
Don’t Know
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?
*
Yes
No
Don’t Know
Please type below any further information which may be relevant:
Have you ever had any of the following vaccinations / malaria tablets?
*
Tetanus
Polio
Diptheria
Typhoid
Hepatitis A
Hepatitis B
Meningitis
Yellow Fever
Influenza
Rabies
Jap B Enceph
Tick Borne
Other / Malaria tablets
Privacy Policy
This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our
Privacy Policy
to discover how we protect and manage your submitted data.
*
I consent to the practice collecting and storing my data from this form.
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