NHS GP GP Pathfinder Clinics
at Hazeldene Medical Centre,
Crest, Eagle Eye and
Chamberlayne Road Surgery
  • Search

  • My accountcomputer-icon
    • English
    • NHS GP
      • Home
      • Prescriptions & Appointments
        • GP Access Video
      • Online Clinical Services
        • Self Care
        • NHS App
        • NHS Coronavirus Test
        • Dermatology
        • Health A to Z
        • Non-NHS Services
      • Students
        • University Student Wellbeing
      • About Us
        • Corporate
        • Health Blog
        • Bereavements
        • Care Data Info
        • Careers
        • CQC Inspection
        • Complaints
        • Contact Us
        • FAQ
        • Friends and Family Test Results
        • Meet Our Team
        • Our Locations
        • Patient Reviews
        • Safe Surgery
        • What Do We Treat
        • GP Earnings
      • Register Online

      Dr Harriet Bradley

      Previous post
      Sharmithan Thirulogachandar
      Next post
      Natacha Morar
    • Find ClinicRegister Online
      • Home
      • Prescriptions &
        Appointments
      • Online Clinical Services
      • Students
      • Corporate Website
    • Alperton

      The Eagle Eye Surgery
      26 Eagle Road
      HAO 4SH
      Phone: 020 8902 8223

      Queen’s Park

      Chamberlayne Rd Surgery
      124 Chamberlayne Road
      NW10 3JP
      Phone: 020 8206 6590

      Willesden

      Crest Medical Centre
      157 Crest Road
      NW2 7
      Phone: 020 8452 5155

      Wembley

      Hazeldene Medical Centre
      1b Wyld Way
      HA9 6PW
      Phone: 020 8902 4792
    • Terms Of Use | Privacy & Cookie Policy | Trading Terms | Physical Accessibility Statement
      © 2022. The Content On This Website Is Owned By Us And Our Licensors. Do Not Copy Any Content (Including Images) Without Our Consent.
    • Register
      Online
    • ×
      lifestyle-Form

      Change of Contact Details

      Change of Contact Details
      Sex(Required)
      DD slash MM slash YYYY
      Are you a student?(Required)

      Comments and Suggestions Form

      Comments and Suggestions Form
      This is the easiest way to make a complaint or leave a comment for us.
      What kind of comment would you like to send? Remember this form is not for medical matters.
      Your comment is:
      Your contact details
      Do you agree to be contacted regarding this matter?(Required)

      Sick Note Request form

      Requesting Fit Note (Med3)
      The more information you put in this form, the more opportunity we have to help you with your Fit note request
      Your details:
      DD slash MM slash YYYY
      The next part of this form, is you opportunity to clarify why you are asking for a fit note.
      DD slash MM slash YYYY
      DD slash MM slash YYYY
      Please email any supporting documents to docman.e84066@nhs.net

      Alcohol Questionnaire for Adults

      This is the easiest way to make a complaint or leave a comment for us.

      Alcohol Questionnaire for Adults
      This is the easiest way to make a complaint or leave a comment for us.
      Your contact details
      DD slash MM slash YYYY
      Alcohol
      1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits.
      1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units.

      Application to Register with a General Medical Practitioner

      Application to Register with a General Medical Practitioner
      Patient's Details

      Please complete the text boxes and tick where appropriate

      DD slash MM slash YYYY
      Sex:
      Patient's Details
      If you are from abroad
      MM slash DD slash YYYY
      MM slash DD slash YYYY
      If you are returning from the armed forces
      DD slash MM slash YYYY
      If you are registering a child under 5
      If you need your doctor to dispense medicines and appliances
      DD slash MM slash YYYY
      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.

      Tick here if you have given blood in the last 3 years
      Supplementary questions
      PATIENT DECLARATION for all patients who are not ordinarily resident in the UK
      Anybody in England can register with a GP practice and receive free medical care from that practice.However, if you are not 'ordinarily resident' in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of 'indefinite leave to remain' in the UK.Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice.You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.
      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.
      Please tick one of the following boxes:
      I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.(Required)
      NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS
      If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC)/S1, you may be billed for the cost of any treatment received outside the GP practice, including at hospital).
      Do you have a non-UK EHIC or PRC?
      If yes, please enter details from your EHIC or PRC below:
      DD slash MM slash YYYY
      DD slash MM slash YYYY
      PRC validity period
      DD slash MM slash YYYY
      DD slash MM slash YYYY
      Untitled(Required)
      How will your EHIC/PRC/S1 data be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process. Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

      Are You A Carer?

      Do you look after a family member or friend who is unwell, disabled or frail?

      Are You A Carer?
      Do you look after a family member or friend who is unwell, disabled or frail?
      If so please complete this form. Once you are added to our list of carers we will know about your busy life as a carer, which can affect your health. We can also try and be flexible with appointments etc as we will know about your commitments.
      Carer details
      DD slash MM slash YYYY
      Details of Person Being Cared For
      DD slash MM slash YYYY
      Is the person you care for a patient at NHS GP?

      Asthma Annual Review Questionnaire

      Asthma Annual Review Questionnaire
      Contact details
      DD slash MM slash YYYY
      Questionnaire
      5. In the last month has your asthma interfered with your usual activities (e.g. housework, work, school etc)?
      6. Have you ever had your peak flow measured at the surgery?
      7. Are you happy with your inhaler technique?
      If you are not, did you know there is an online demonstration on the Asthma UK website or you could pop in and see our practice nurse for more advice.
      8. Have you ever smoked?
      If 'Yes', please answer the following:
      Do you smoke now?
      There are plenty of options available to help you quit. Is this something you would like us to contact you about?

      Change of Contact Details

      Change of Contact Details
      Sex(Required)
      DD slash MM slash YYYY
      Are you a student?(Required)

      Comments and Suggestions Form

      Comments and Suggestions Form
      This is the easiest way to make a complaint or leave a comment for us.
      What kind of comment would you like to send? Remember this form is not for medical matters.
      Your comment is:
      Your contact details
      Do you agree to be contacted regarding this matter?(Required)

      Advice in your region

      England | Scotland | Wales | Northern Ireland | Ireland

      Get the latest NHS information and advice about coronavirus (COVID-19).

      Check if you or your child has coronavirus symptoms

      Find out about the main symptoms of coronavirus and what to do if you have them.

      Self-isolation and treatment if you have coronavirus symptoms

      Advice about staying at home (self-isolation) and treatment for you and anyone you live with.

      Testing and tracing

      Information about testing for coronavirus and what to do if you're contacted by the NHS Test and Trace service.

      People at high risk

      Advice for people at higher risk from coronavirus, including older people, people with health conditions and pregnant women.

      Social distancing and changes to everyday life

      Advice about avoiding close contact with other people (social distancing), looking after your wellbeing and using the NHS and other services during coronavirus.

      GOV.UK: coronavirus – guidance and support

      Government information and advice.

      New Patient Health Questionnaire for Adults

      New Patient Health Questionnaire for Adults
      Your contact details
      Title:
      DD slash MM slash YYYY
      Information about you
      Do you need an interpreter?(Required)
      Previous GP
      Proof of Identity and Address Provided
      Medical Information
      Have you ever suffered from? (tick as appropriate)
      Epilepsy
      Heart Attack/Stroke
      High Blood Pressure
      Cancer
      Eczema/Hay Fever
      Blindness/Glaucoma
      Diabetes
      Depression
      Asthma
      COPD
      Are you registered disabled?
      Have you ever refused treatment/screening of any kind?
      Are you allergic to any medicines?
      Have you ever suffered from? (tick as appropriate)
      Anxiety
      Depression
      OCD
      Bipolar Disorder
      Carers
      Do you have a carer?
      Are you a carer?
      Wills
      Do you hold a Living Will?
      (A Living Will is documentation regarding your personal wishes in respect of medical intervention at the time of serious illness)
      Women
      Have you ever had a cervical smear?
      Smoking
      Do you smoke?
      If 'No', have you ever smoked?
      Would you like advice on giving up smoking?
      Alcohol
      1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits
      Family History
      Next of Kin
      Contacting you
      For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)
      Untitled(Required)

      Registering with a GP surgery outside the area you live?

      You do not need to register with a GP surgery in the area you live.

      Registering with a GP surgery outside the area you live?
      You do not need to register with a GP surgery in the area you live.
      You can register with a surgery that's more convenient, for example closer to your work or your children's school..
      The GP surgery can refuse registration for reasons such as they are not taking new patients or it's too far away from your home and you need home visits.
      Your details
      DD slash MM slash YYYY
      Reason for registering with our practice in London
      Terms of Registering with GP far away from home.
      The surgery will decide if they can accept you as a regular patient or accept you without home visits.
      Because of the distance to your home, the GP surgery might not be able to offer home visits.
      If you are not well enough to go to the GP surgery, other arrangements might be made.
      Registering with a practice further away from home can affect decisions about referrals for hospital tests and treatment, or access to community health services
      Additionally the offer of Cancer Screen Services  and practice based Blood Tests and Investigations maybe a long distance for you to travel
      Do you accept the Terms of Registering with a GP far away from home?

      Repeat Prescription Request Form

      Repeat Prescription Request Form
      Patient 1 details
      DD slash MM slash YYYY
      You may request up to twenty separate items. Enter each drug and strength on your prescription. Untick the 'Required' box if you do not require the item this time. Please note that items will only be dispensed if they are included on your repeat prescription and a medication review is not pending
      Untitled
      Untitled
      Untitled
      Untitled
      Untitled
      Untitled
      Untitled
      Untitled
      Untitled
      Untitled
      Untitled
      Untitled

      Request to Register for Online Services

      Request to Register for Online Services
      Your details
      DD slash MM slash YYYY

      Signing Up For Patient Reference Group

      Signing Up For Patient Reference Group
      If you are happy for us to contact you periodically by email please fill out all the fields below and send the completed form to us.
      Your details
      DD slash MM slash YYYY
      The information below will help to make sure that we receive feedback from a representative sample of the patients registered at this practice.
      Your Gender
      Your Age
      The ethnic background with which you most closely identify is:
      How would you describe how often you come to the practice?

      The General Practice Assessment Questionnaire (GPAQ)

      The General Practice Assessment Questionnaire (GPAQ)
      3 b) What additional hours would you like the practice to be open? (please tick all that apply)

      Travel Questionnaire

      Travel Questionnaire
      Personal Details
      MM slash DD slash YYYY
      Trip Dates
      DD slash MM slash YYYY
      Itinerary
      Trip Description - please tick all appropriate boxes:
      Purpose of trip:
      Type of trip:
      Accomodation:
      Travelling:
      Location type:
      Activity type:
      Personal medical history
      Untitled
      Untitled
      Untitled
      Untitled
      Untitled
      Untitled
      Untitled
      Untitled
      Have you ever had any of the following vaccinations / tablets and if so, when?

      Your Accessibility Needs

      Your Accessibility Needs
      We want to get better at communicating with our patients. We want to make sure you can read and understand the information we send you. If you find it hard to read our letters or if you need someone to support you at appointments, please let us know.
      Your Details
      DD slash MM slash YYYY

      Sick Note Request form

      Requesting Fit Note (Med3)
      The more information you put in this form, the more opportunity we have to help you with your Fit note request
      Your details:
      DD slash MM slash YYYY
      The next part of this form, is you opportunity to clarify why you are asking for a fit note.
      DD slash MM slash YYYY
      DD slash MM slash YYYY
      Please email any supporting documents to docman.e84066@nhs.net

      We use cookies to improve your experience

      We use cookies to make our website work better for you and to understand how it's used. You can choose to accept or reject optional cookies.

      More information