Register With Us


Thank you for your interest in registering with the Queens Crescent Practice.  We now work in partnership with the James Wigg Practice located nearby.

The Queens Crescent Practice gives you the best of both worlds - a homely, friendly and intimate setting in high quality premises; while also giving you access to the great range of services and facilities of the Kentish Town Health Centre.  Many of the clinical and administrative staff work across both sites to provide an excellent standard of care. 

New patients can register with the practice online by completing the form further down this page. It would help us if you fill in as much information as you have available, but items marked with * must be completed. Please submit a separate form for each family member.

Please allow 2 working days for your registration for to be processed. You will be sent an additional form in the post as well an opt form for current NHS data sharing CIDR care.data Summary Care Record In order to have the information the practice needs to complete your registration, please return the forms ASAP in the self addressed envelope provided. You will also be asked to bring proof of address when you first attend the practice. 

please submit a separate form for each family member.

If you would like to check whether you are within our catchment area, please click the link below and type in your post code and see if it falls within the highlighted section

https://www.primarycare.nhs.uk/publicfn/catchment.aspx?oc=F83632&h=600&w=800&if=0



NHS Family doctor services registration

Patient's details
* Title
* Surname
* First Names
Previous surname
* Gender
* Date of birth
* Town and Country of Birth
* Were you born in London

* Current home address
* Postcode
* Telephone number
* Email ID
I consent to receiving personal data via email
NHS Number
* Are you from abroad
Your first UK address where registered with a GP
If previously resident in UK,
date of leaving
* Date you first came to live in UK
Medical records

If you have been registered with a GP before, please help us trace your previous medical records by providing the following information

* Your previous address in UK
* Name of previous doctor while at that address
* Address of previous doctor
If you are returning from the Armed Forces
Address before enlisting
Service number
Enlistment Date
If you are registering a child under 5
  I wish the child above to be registered with a Doctor from the James Wigg Practice for Child Health Surveillance.
If you need doctor to dispense medicines and appliances
 

I live more than 1 mile in a straight line from the nearest chemist.

 

I would have serious difficulty in getting them from a chemist.

NHS Organ Donor registration

I want to register my details on 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.

 

Tick here if you have given blood in the last 3 years

Next of Kin
* Name of Next of Kin
* Relationship to you
* Phone number
Children Details
Name Sex Date of Birth
Name Sex Date of Birth
Name Sex Date of Birth
Name Sex Date of Birth
Name Sex Date of Birth
For Children under 16
Who looks after you?




Which school do you go to?
Type of Accommodation*

         

Occupation*

       

Height & Weight
How tall are you*
How much do you weigh*
Carer Details
Are you a carer? *

If Yes, who do you care for?

Do you have a carer? *

If Yes, Carer's Name:

Ethnic Group
What best describes you?*

Please provide a description

General Questions
What is the first or main language that you speak*
Do you ever need an interpreter *
Medical History
Have you had any other Long Term Condition, Illness, Accident or Operation
1. Condition/Operation
Date/Year
Hospital
2. Condition/Operation
Date/Year
Hospital
3. Condition/Operation
Date/Year
Hospital
4. Condition/Operation
Date/Year
Hospital
Allergies
* Are you allergic to any medication
(such as Penicillin or Aspirin)

If Yes, please give details

Smoking
* Do you smoke now

If Yes, how many per day and what kind?

* Did you smoke in the past

If Yes, how long?

Alcohol
* How often do you have an alcoholic drink?





* How many drinks/units per session?





* How often do you have 6 or more standard drinks on one occasions?




Your Family's Health
Has anyone in your family had a heart attack or angina*
If Yes, Please Tick*

If Other, please specify

Have members of your family suffered from any other health problems*

If Yes, please specify

Proof of ID & Address
Please attach a scanned copy of your Proof of Address

Valid proof of address include Bank & Utility Statement, Tenancy Agreement, Council Letters, Pensions and Benefit letters from DWP. Mobile Phone bills are not valid

Please attach a scanned copy of your Proof of ID

Valid proof of address include Passport, Driving licence, ID Card

Where did you hear about us
Final Declaration*
 

I would like to have a Patient Access account in to re-order prescriptions and medications, book appointments online

 

I acknowledge that all the information provided is accurate to the best of my knowledge. By ticking this option, I take responsibility and consent to the practice registering me as a regular patient