Gower Street Practice
Student Patient Registration

Please fill in your details and click Next when complete. * = compulsory

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 to do so.
Please do not use this form to update your address or other details.

* Name of your college or institution:

* Study course:

* Approximate finish date of course:

* Title:

Mr Mrs Miss Ms

* Surname:

* All first names:

Previous surname/s:

* Date of birth:

NHS No. (if known):

Gender:

Male Female

* Town and country of birth:

Please select your Student Halls from the list below OR fill in your new ADDRESS:

Student Halls:

House/Room/Flat/Studio/Block no:

* Street:

* Town:

* Postcode:

Mobile telephone number:

	* Name:
Next of kin details	* Phone no:
	* Relationship:

* If required in an emergency situation, do you give Gower Street Practice the permission
to discuss your medical records with the above person? Yes No

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:

UK Student
International Student

Part 2: Fill in if you come from the UK
* Previous Address in UK: (i.e. last address before going to Uni/College) * Town: * Postcode:
* Name of Doctor or Surgery when at that address:
Address of Doctor or Surgery: Postcode:

* E-mail Address:

* Confirm E-mail Address:

* Signature:

Clear

* Confirmation:

By ticking this box I confirm that I have filled
in this form to the best of my knowledge
and signed it with my own unique mark.

New Patient Health Check Form

* Do you SMOKE?	Yes No
If currently a non smoker, have you ever smoked?	Yes No	If Yes, when did you give up?

* Do you suffer from any ALLERGIES? Yes No

* Do you have any LONG-TERM CONDITIONS, e.g. diabetes or asthma ? Yes No

* What is your ETHNICITY: Other:

* Are you a CARER for someone else?

Yes No

* Do you have a carer?

Yes No

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..

Gower Street PracticeStudent Patient Registration

New Patient Health Check Form

Gower Street Practice
Student Patient Registration