I consent to the practice contacting by email for non-confidential matters
I consent to the practice contacting me by text message for the purpose of the appoint reminders/invites
Please help us Trace your previous Medical records by providing the following information (UK STUDENTS ONLY)
Your previous address in UK
If you are an international student you MUST complete the questions below
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 ordinarily residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available form you 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 ordinarily residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available form you 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.
Please tick one of the following boxes
A parent/ guardian should complete the form on behalf of a child under 16.
I declare that the information I give on this form is correct and complete. I understand that is is not correct, appropriate action may be taken against me.
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 is you have an EHIC issued by the UK
NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS
Do you have a non-UK EHIC or PRC?
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.
You will not be registered without providing the information required below.
Accountable GP – All patients have been allocated an accountable named GP. You will be sent an email with the name of your GP following successful registration. This does not affect your ability to book an appointment with any GP. For more information please ask at reception.
If you smoke, would you like support & treatment to help you stop?
Do you currently suffer from any of the following?
Do you suffer/have suffered from Asthma?
If you have ticked any of the boxes above, you will need to book an appointment with the Practice Nurse for a review your earliest convenience.
We also offer a Health Check with one of our practice nurses to all patients who are on regular medication or are over 40 years of age.
Are you a Carer? (providing a support for a student)
Do you have a carer? (Whilst at University)
If yes, please complete the following:
What is your preferred method of communication?
Preferred correspondence format?
Please note we will record the above information and add an alert message
Summary Care Record
A Summary Care Record is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had. This information makes it easier for health care staff to treat you in an emergency or when your GP practice is closed.
We offer free HIV Tests (Ask at reception for more information)
Please tick this box to confirm that you have read the information in regards to HIV Testing.
I have read the above. I confirm the information provided is a full and correct record of my medical history.
Fast Alcohol Screening Test
For the following questions – 1 standard drink = 1 unit of alcohol
An indication of a standard drink is as follows:
Half pint of regular beer, larger or cider.
Small glass of wine
Single measure of spirit
Single measure of aperitifs
Only answer the following questions if the answer above is Never (0), Monthly (1) or Less than monthly (2). Stop here if the answer is Weekly (3) or Daily (4).
Please type your total score below based on the answered provided in the FAST ALCOHOL SCREENING TEST
Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.
All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.