Practice Name

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.

* 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
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

* Course Details
Only applies to students
        Only applies to students. Approximate end date of course.
Have you ever served in
* 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 drink ALCOHOL?    
Guidance says that men and women shouldn't regularly drink more than 14 units a week.
Go to the Unit Calculator to see how much you drink each week...
* Do you SMOKE or VAPE?           
* Amount you smoke per day:  
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):
DTP and Polio:
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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