Student Registration Form

Fields marked "REQUIRED" are compulsory.. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 12/09/2023

Patients Details

Please fill in your details accurately

Title *

First name(s) *

Surname *

Previous Surname

Birth Town *

Birth Country *

Date of Birth (DAY/MONTH/YEAR) *

NHS number

Sex

Male

Female

Name of Student Accommodation (If living in Student Accommodation)

Block

Room

Flat

Address *

Postcode *

Telephone *

Email Address *

Please help us trace your previous medical records by providing the following

Have you had a GP in the UK before? (If yes, please answer the next question) *

Yes No

Your previous address in UK (n/a if you are from abroad) *

Name of previous GP while at previous address

Address of that Doctor

If you are 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 (n/a if born in the UK) *

If you are returning from the armed forces

Address before enlisting

Service/Personnel No.

Enlistment date

Information About You

Please fill in the following questions as accurately as possible.

Course Details

Please answer the following questions about your course details accurately

Which course are you studying currently? *

In which month and year does your course end? *

Smoking

Please fill in the questions below.

Do you smoke? *

Yes No

If yes, how many cigarettes or ounces of tobacco do you smoke per day?

Alcohol

Please note, a single small shot of spirits (25ml) is 1 unit, a small glass of wine is 1.5 units, a bottle of beer/cider/lager (330ml) is 1.7 units and a pint of beer/cider/lager is 2 units).

How often do you have a drink containing alcohol? *

How many units of alcohol do you drink on a typical day? *

How often have you had 6 or more drinks on one occasion? *

How many units of alcohol do you drink in a week?

Next of Kin

Please state the name, address, telephone number and relationship of your next of kin. *

Contacting you

Please state whether we can contact you by filling in questions below.

Do you agree to be contacted by the practice via email or SMS with practice news and appointment reminders? *

Yes No

Online Services

This will enable you to access the online booking system, order your prescriptions online and view test results.

Would you like access to online services? *

Yes No

Summary Care Record

What does it mean if I DO NOT have a Summary Care Record? NHS healthcare staff caring for you may not be aware of your current medications, allergies you suffer from and any bad reactions to medicines you have had, in order to treat you safely in an emergency. Your records will stay as they are now with information being shared by letter, email, fax or phone. If you have any questions, or if you want to discuss your choices, please contact your GP practice.

Do you consent for your clinical information to be included within the summary care record? *

Yes No

Complete Registration

Please complete this section below.

If you are registering a child under 5

I wish the child above to be registered with the named doctor for Child Health Surveillance

If you need your 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

Signature

Signature of patient

Signature on behalf of patient

Signed *

Date *

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Cookies on the University Medical Practice website

Student Registration Form

Further Information