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New Patient Registration

Personal Details

Note: This information is used to monitor equality between groups of people of different sexual orientations. Equality monitoring helps make sure that everyone is treated fairly.
Next of Kin Full name

Summary Care Record

Medical History

Previous Doctor (GP / Family Doctor) Name
Practice Name
Telephone No
Selected Value: 0
To improve your health, we recommend that you stop smoking. If you are interested in giving up smoking please speak to a member of staff.

Alcohol intake

Chronic conditions

Family Medical History

Important Notes:

➢ Please note that you will be unable to see a GP until your registration is complete. This includes the processing of all completed forms and having an appointment to see the Doctor for a New Patient Health Check.

➢ If you are going to require repeat medication immediately after registration without seeing a doctor, from your previous GP and pass it to the receptionist with your written repeat prescription request. We will be unable to issue repeat prescriptions without an appointment with a doctor if this information is not provided.

➢ Please bring one ID proof (passport/full driving license) and one Address proof (Bank
statement/council tax bill/utility bill)

➢ Useful links
o CCG Website: https://northeastlondon.icb.nhs.uk/your-area/havering/
o NHS Covid-19: https://www.nhs.uk/covid-19-advice-and-services/
o NHS 111/ Emergency: https://111.nhs.uk/
o NHS.UK: https://www.nhs.uk/
o Department of Health and Social Care: https://www.gov.uk/government/organisations/department-of-healthand-social-care
o https://northeastlondon.icb.nhs.uk/
NHS North East London is responsible for planning and buying health services across north east London to meet our population’s needs, making sure all parts of the local health system work effectively together.

Surgery Website: https://www.dpsrgmc.co.uk/

You’re Survey Important for us: https://www.dpsrgmc.co.uk/friends-family-test (your feedback
References: https://rb.gy/adv3l


Dr. Poolo's Surgery
Rush Green Medical Centre.
261 Dagenham Rd, Dagenham, Romford RM7 0XR.

Phone: 01708 209220
Out-Of-Hours: 111

Email: [email protected]
(email strictly for non-clinical queries)

Out of hours

You can now book an appointment at the out of hours PCN Hub at Rush Green Medical Centre, via this QR Code or via this website: https://shorturl.at/adyQ0

The NHS want you to have the best possible experience of care. Please give your feedback.


Pharmacy First


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