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* Have
you ever registered
with this practice before?
Yes
No
* Title:
Mr
Mrs
Miss
Ms
Mx
* Surname
(Family name):
* First
name(s):
Preferred (known as)
first name: (if different from above)
Previous surname(s):
Please enter any
other name you might have been known as:
Mother’s maiden name:
* Date of birth:
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NHS No. (if known):
* Gender:
Male
Female
Are you under the care of gender services?
Yes
No
* Town and country
of birth:
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:
Select...
Aberconway Hall
Aberdare Hall
Adam St Gardens
Arofan House
Blackwier Lodge
Bridge St Exchange
Cambrian Point
Cartwright Court
City Heights
Clodien House
Column Hall
Crown Place
Cyncoed Hall
Eclipse
Glendower House
Gordon Hall
Hodge Hall
Howard Gardens
Liberty
Livin
Lumis
North Court
Plas Gwyn
Roy Jenkins Hall
Senghenydd Court
Senghenydd Hall
Severn Point
Summit
The Fitzalan
The Neighbourhood
The West Wing
Treforest, Pontypridd
TYB Court
TYB Gate
TYB North
TYB South
University Hall
Windsor House
Zenith
Room/Flat/Block:
House:
* Street Address:
* Town:
* Postcode:
* Email address:
* Confirm Email address:
*
UK Mobile telephone
number:
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:
from UK
from Abroad
* Are you currently in the UK?
Yes
No
You cannot register with us
until you are in the UK
Details of person to be contacted in an
emergency
* Name:
* Telephone:
* Relationship:
Have you
ever served in HM ARMED FORCES?
Yes
No
*
Signature:
Health Questionnaire
* How many times
per week do you EXERCISE?
Please select...
None
Once a week
Twice a week
Three times or more
* Do you have any
HEALTH PROBLEMS ? Yes
No
(including asthma, diabetes, mental health etc)
* Please state any
health problems you have:
* Do you have any ALLERGIES
? Yes
No
* Please state any
allergies you have:
* Do you take any MEDICATION at
present? Yes
No
* Please list any
prescribed
medicines you use
including Name, Dosage and Quantity:
* Do you have any
DISABILITY? Yes
No
* Please
describe your disability:
* Do you drink
ALCOHOL? Yes
No
* Do you SMOKE or VAPE?
Smoke
Vape
Never
Used to (not now)
* Amount you smoke per day:
Please select...
Less than 1 per day
1 to 9 per day
10 to 19 per day
20 to 39 per day
40 or more per day
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:
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.