Student Health Centre

Online Registration

Please fill in your details and click Submit when complete.

Please only complete this registration form once. If you have previously submitted this form at any time please
do not do so again unless advised by the Surgery to do so. If you are unsure of your registration status,
you can contact the practice who will be able to confirm this for you.

Current patients: DO NOT use this form to update your address or other details.

* Your preferred language:
* Have you ever registered
with this practice before?
* Title:
Please enter your surname or family name
Please enter your first name
 If you don't know your NHS number it's very important that you fill in part 1 and 2 below
* Gender:  
Select your student accommodation or fill in your new ADDRESS in Cardiff
Please fill in your full and complete address, we can't register you without it.
If you don't know your full address, wait and register when you know it.
Student Accommodation:
* Email address:
* Confirm Email address:
Enter your own telephone number. Preferably your mobile number
* Contacting you
Please help us trace your medical records by selecting if you are from the UK or from Abroad
(Part 1) and then filling in the next section (Part 2)
* Part 1. Select if you are from UK or abroad:
Part 2: Fill in if you come from the UK
(i.e. the address your current GP have for you)





* Are you currently in the UK?   

You cannot register with us until you are in the UK

Part 2: Fill in if you come from abroad (international student)
You can't register before you arrive in the UK
Have you been registered with
a GP in the UK before?
   
Details of person to be contacted in an emergency
   
* University Course Details
       
   
Have you ever served in
HM ARMED FORCES?
   
   
* Signature:
Please draw your unique signature in the box
   
Health Questionnaire
* Ethnic origin:
 
cm kg
 
* Do you have any HEALTH PROBLEMS ?    
(including asthma, diabetes, mental health etc)
* Do you have any ALLERGIES ?    
* Do you take any MEDICATION at present?    
   
* Do you have any DISABILITY?    
   
 
* Do you SMOKE?     
* Amount you smoke per day:  
We offer advice on smoking and a smoking cessation clinic in the surgery.
 
VACCINATIONS
There is an increased risk of Meningitis, Measles, Mumps and Rubella due to the large
numbers of students in the close confines of a university campus, therefore
it is important that you are vaccinated to protect both yourself and others.
Please indicate if you have/have not had the following:
Meningitis C:
MMR (measles, mumps, rubella):
Tuberculosis:
DTP and Polio:
 
NHS Organ Donor Registration
To become an organ donor in Wales you can register a decision on the NHS Organ Donor Register
by ticking the relevant boxes below, or choose to do nothing. By doing nothing you will be considered
as having no objection to organ donation and your consent may be deemed to be given.
If you do not want to become an organ donor you can register this decision on the Organ
Donor Register. You can do this by going to the website or calling 0300 123 23 23.
It is not possible to offer the facility to opt out via this form at the present time.
 
NHS Blood Donor Registration
 
Please read our Privacy Notice.
The information you are submitting will be sent encrypted to the medical practice over the Internet, which still isn't 100% secure.
If you are worried about this you can instead obtain a form from the medical practice that can be filled in and delivered by hand.
* = Compulsory.
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