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

Have you ever registered with this practice before?	Yes   No
* Connection to the University:	Please select an option... Student Family member of student Member of staff No connection to the University
* Title:	Mr   Mrs   Miss   Ms
* Surname:
* First name(s):
Previous surname(s):
* Date of birth:	Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916
NHS No. (if known):
* Gender:	Male (incl trans)   Female (incl trans) Non Binary   Other:
* Is this your gender from birth?	Yes   No
* Town and country of birth:
Please select your new home ADDRESS from the list OR fill it in below:
Student Accommodation:	Select House/Hall... Anchor Court, A Flats Anchor Court, B Flats Anchor Court, C Flats Anchor Court, D Flats Ashenhurst Aspley House , Block A-D Aspley House, Block E-H Bankfield Road Boothroyd Court, A Flats Boothroyd Court, B Flats Boothroyd Court, C Flats Boothroyd Court, D Flats Broomfield House Byram Court Canalside The Castings Chantry House Cinder Hill Court, A Flats Cinder Hill Court, B Flats Cinder Hill Court, C Flats Cinder Hill Court, D Flats Cinder Hill Court, E Flats The Courtyard Firth Point Jenkinson Court, A Flats Jenkinson Court, B Flats Jenkinson Court, C Flats Jenkinson Court, D Flats Kingsmill Studios, 1-44 Kingsmill Studios, 45-94 Lancaster House Little Aspley House The Melting Point, 1 Commercial St The Melting Point, 3 Commercial St The Melting Point, 1 Firth St The Melting Point, 3 Firth St The Melting Point, 5 Firth St The Melting Point, 7 Firth St Myers Court, A Flats Myers Court, B Flats Myers Court, C Flats Myers Court, D Flats Myers Court, E Flats North Point Living Oldgate House, Studio 0-2 Oldgate House, Studio 3-5 Oldgate House, Studio 6-8 Palace Studios Rifle Fields Saw Mill Sir John Ramsden Court Snow Island Stewart Tudor House Viaduct Works York House
Block/Flat/Room:
House name:
* Number and Street:
Area:
* Town:
* Postcode:
If you don't have a HD postcode, please contact the practice before completing this registration form.
* Mobile telephone number:
* E-mail address:
* Confirm e-mail address:
* May we contact you using email?	Yes    No
* May we contact you using SMS text?	Yes    No
* What is your preferred contact method?	SMS/Text    Email    Phone call     Letter
* Full name: EMERGENCY CONTACT  * Phone no:   * Relationship:
Have you previously been    registered with the Forces?	Yes    No
Please help us trace your medical records by selecting if you are from 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
Part 2: Fill in if you come from the UK * Previous Address in UK: (i.e. last address before moving here) * Town: * Postcode: * Name of Doctor or Surgery when at that address: * Address of Doctor or Surgery: Postcode:
Part 2: Fill in if you come from abroad * Date when you arrived in UK: Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Have you lived or studied in the UK before? Yes    No Your first UK address where registered with a GP: (only if you have previously registered with a GP) Town: Postcode: If a previous resident in UK, date of leaving: Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Supplementary Questions: Anybody in England can register with a GP practice and receive free medical care from that practice. However, if you are not 'ordinarily resident' in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside of the European Economic Area must also have the status of 'Indefinite leave to remain' in the UK. Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges. More information on ordinary residence, exemption and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice. You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment regardless of advance payment. The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purpose of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided. Please select one of the following options: More information... I understand that I may need to pay for NHS treatment outside of the GP practice I understand that I have a valid exemption for paying for NHS treatment outside of the GP Practice. I can provide documents to support this when requested This includes for example, an EHIC, or payment of the Immigratin Health Charge ("the Surcharge"), when accompanied by a valid visa. I do not know my chargeable status 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? Yes   No Please enter details from your EHIC or PRC below: Country code: 3 Family Name: 4 Given names: 5 Date of Birth: (dd/mm/yyyy) 6 Personal Identification Number: 7 Identification Number of the Institution: 8 Identification number of the card: 9 Epiry Date: (dd/mm/yyyy) PRC validity period From: (dd/mm/yyyy) PRC validity period To: (dd/mm/yyyy) Tick here if you have an S1 (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... How will your EHIC/PRC/S1 date be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purpose of cost recovery. Your clinical data will not be shared in the cost recovery process. Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.
* Signature:	Clear
Health Questionnaire
* Ethnic origin: Please select... British Irish Irish Traveller Traveller Gypsy/Romany Polish Any other White (please specify) White and Black Caribbean White and Black African White and Asian Any other Mixed (please specify) Indian Pakistani Bangladeshi Any other Asian (please specify) Caribbean African Somali Nigerian Any other Black (please specify) Chinese Filipino Any other ethnic group (please specify) Prefer not to say Other:   Religion:       1st language: Need interpreter: Yes   No   * Nationality: * Home country:
* Height:  cm * Weight:  kg Your Body Mass Index (BMI) is: Please contact the practice for advice if your BMI is over 30.
Physical Activities and Eating Habits: * Do you exercise? Yes   No * Which best describes your diet? Select... Good Diet Average Diet Poor Diet
Are you a carer? Yes  No  Do you have a carer? Yes  No Who do you care for? Who cares for you?
* Please tick if you have, or have had, any of the following ILLNESSES or none:   Asthma: Osteoporosis: Cancer: Coronary Heart Disease: COPD: Mental health problems: Chronic Kidney Disease: Dementia: Diabetes: Depression: Epilepsy: Eating disorder: Heart failure: Peripheral Arterial Disease: High blood pressure: Rheumatoid Arthritis: Atrial Fibrillation: Sickle Cell:         NONE of the above:
Please list any other existing or past SIGNIFICANT MEDICAL CONDITIONS including major operations and dates: Please list any CURRENT MEDICATION, including inhalers and contraception. Please specify dose: Please list any DRUG ALLERGIES or ALLERGIC REACTIONS: FAMILY HISTORY Has anyone in your immediate family suffered from... Heart disease (under 60): Heart disease (over 60): High blood pressure: Diabetes: Stroke:
* Do you SMOKE? Yes   No   Used to smoke
* Amount you used to smoke per day:      When did you stop? * Amount you smoke per day:
* How many alcohol units per week do you drink?   NHS Alcohol Unit Calculator
How often do you have a drink that contains ALCOHOL? Never Monthly or less 2-4 times / month 2-3 times / week 4+ times / week
How many standard alcoholic drinks do you have on a typical day when you are drinking? 1-2 3-4 5-6 7-9 10+
How often do you have 6 or more standard drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily
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? Never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily (4)   How often during the last year have you failed to do what was normally expected from you because of your drinking? Never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily (4)   How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? Never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily (4)   How often during the last year have you had a feeling of guilt or remorse after drinking? Never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily (4)   How often during the last year have you been unable to remember what happened the night before because you had been drinking? Never (0) Less than monthly (1) Monthly (2) Weekly (3) Daily or almost daily (4)   Have you or somebody else been injured as a result of your drinking? No (0) Yes, but not in the last year (2) Yes, in the last year (4)   Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? No (0) Yes, but not in the last year (2) Yes, in the last year (4)   Scoring (add up score in brackets): 0 – 7 Lower risk, 8 – 15 Increasing risk, 16 – 19 Higher risk, 20+ Possible dependence
* Do you use recreational DRUGS? Yes   No Which drug(s)?
Do you have a Disability or Special Communication Needs?   Yes   No Please describe your disability: Please provide your preferred means of communication: Text:  Email:  Sign Language:  Hearing Loop:  Other: * Please note not all information is currently readily available *
Immunisations
Please indicate if you've had any of the following immunisations, and when:
MMR1:   Yes   No    Date/year: MMR is generally given when a child.   MMR2:   Yes   No    Date/year:   Meningitis ACWY:   Yes   No    Date/year:               * 1st COVID-19 dose:   Yes   No    Full date: Vaccine name: * 2nd COVID-19 dose:   Yes   No    Full date: Vaccine name:
People with a cervix over the age of 25 Have you ever had a smear test?  Yes   No Date: Where: Result: 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?  Yes   No Indicate vaccine (if known):  Cervarix   Gardasil First date: Second date: Third date:
* 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.
I agree to opt in   I do not agree to opt in
General Data Protection Regulations
CONSENT FORM
I hereby give consent under the new General Data Protection Regulations 2018 for:
My medication to be ordered Prescriptions, letters & sick notes to be collected Appointments made on my behalf/referral to secondary care (hospital appointments etc) Signature: Clear
You have the right to withdraw your consent at any time. It is the responsibility of the patient to inform the practice of any change of personal data under the new General Data Protection Regulations 2018.
ELECTRONIC HEALTH RECORD ACCESS Online services of all types are vulnerable to coercion. In the context of Patient Online, coercion might result in patients being forced into sharing information from their medical record, including login details, medical history, repeat prescription orders, GP appointment booking details and other private, personal information. * Would someone else ask for your access to your medical information if you were given online access? Yes   No We are able to offer full access to your medical records. If you are interested in this service please speak to the reception staff or visit our website for more information.
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.