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 Health Centre 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.

* 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:     More information...
Please select your student accommodation or fill in your new ADDRESS in Durham:
Student Accommodation:
* Email address:
* Confirm Email address:
Enter your own telephone number. Preferably your mobile number
* May we contact you using email?   
* May we contact you using SMS text?   
Enter a person (full name including surname) we should contact in case of an emergency
Enter a phone number to the emergency contact
Enter your relationship to the emergency contact
Please help us trace your medical records by selecting if you are a UK or International student
(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 will have for you)

Part 2: Fill in if you come from abroad (international student)
You can't register before you arrive in the UK
Have you lived or studied in the UK before?    
Supplementary Questions (optional)
Please select one of the following options: More information...
Complete the following section if you come from another EEA country:
Do not complete this section if you have an EHIC issued by the UK.
Do you have a non-UK EHIC or PRC?   

(e.g. if you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state). Please give your S1 form to the practice staff. More information...
* Signature:
Please draw your unique signature in the box
Health Questionnaire
* Ethnic origin:
Need interpreter:   
Are you a carer?     Do you have a carer?  
Are you a Veteran?         
 cm  kg
* Do you SMOKE?
How often do you have a drink that contains ALCOHOL?
NHS Alcohol Unit Calculator
How many standard alcoholic drinks do you have on a typical day when you are drinking?
How often do you have 6 or more standard drinks on one occasion?
If your total alcohol score above is high it may indicate hazardous or harmful drinking.
Please then complete the more detailed questions below (score in brackets):
How often during the last year have you found that you were not able to stop drinking once you had started?
How often during the last year have you failed to do what was normally expected from you because of your drinking?
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?
How often during the last year have you had a feeling of guilt or remorse after drinking?
How often during the last year have you been unable to remember what happened the night before because you had been drinking?
Have you or somebody else been injured as a result of your drinking?
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?
Your alcohol score is: 0
0 – 7: Lower risk, 8 – 15: Increasing risk, 16 – 19: Higher risk, 20+: Possible dependence
If your score is 8 or more, your answers suggest you may be at increased risk of future harm to your health from drinking.
Further information about this can be found at
IMMUNISATIONS - essential information required

You are strongly advised by UHS to ensure that you are
fully immunised to UK Department of Health standards.

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 ACWY vaccine:
* 1st MMR (measles, mumps, rubella) vaccine:
* 2nd MMR (measles, mumps, rubella) vaccine:

* Have you been diagnosed with any of the following CONDITIONS?
Please enter onset date.

Have you had/do you suffer from any OTHER serious illness
or condition not mentioned above?
Have you had any significant INJURIES or OPERATIONS?    
Do you have any DISABILITY/COMMUNICATION needs?    
Do you suffer from any ALLERGIES?    
Do you take any prescribed MEDICATION at present?    
(including the pill and depo-injections)
Have you ever had a smear test?    
If you are over 25 and have not yet had a smear please make an appointment with the Practice Nurse.
Have you had HPV VACCINATION?    
NHS Records
There are strict laws and regulations to ensure that your health records are kept confidential and can
only be accessed by health professionals directly involved in your care. There is some sharing
of information as detailed below. You can opt out of any of these at any time if you wish.
NHS Summary Care Record (SCR) - this 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. Having this information stored
in one place makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed.

Named Accountable GPs
On registration with the practice you will have a nominated GP, should you wish to know
who that is please contact the practice after your arrival in Durham. The practice has a
team based approach, you can therefore book an appointment with any GP.

Patient Online Access
Once your registration has been processed you will able to download
the NHS app to your mobile or tablet, making it much easier to make
appointments, order repeat medication or view your medical record

Organ Donation
Organ donation in England has moved to an 'opt out' system. This means that all
adults in England will be considered to have agreed to be an organ donor when
they die unless they have recorded a decision not to donate or are in one of the
excluded groups. For further information: 
Blood Donation
If you are interested in becoming an blood donor, please click this link
to go to the blood donor website.
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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