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 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

* Title:

Mr Mrs Miss Ms Mx Other:

* Surname:

* First name(s):

Previous surname(s):

* Date of birth:

NHS No. (if known):

* Gender:

Male (incl trans men) Female (incl trans women)
Non-binary Other:

* Do you identify as trans?

Yes No

* Town of birth:

Borough (if London):

* Country of birth:

Please select your student Hall and enter your Flat/Room
or fill in your NEW HOME ADDRESS below:

Student Hall:

Block/Floor/Flat/Room/Number:

House:

* Street:

* Town:

* Postcode:

Mobile telephone number (UK only):

Guidance

* E-mail address:

Guidance

* Confirm e-mail address:

* May we contact you using email?

Yes No

* May we contact you using SMS text?

Yes No

* Preferred contact method:

	Full name:
UK Trusted Contact	Phone no:
	Relationship:

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)

Block/Floor/Flat/Room/Number:

House:

* Street:

* Town:

* Postcode:

* Approximate Date of first living at this address:

* 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:

Guidance

Have you lived or studied in the UK before?

Yes No

Supplementary Questions:

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

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...

* Signature:

Clear

College Information

* College:

Imperial College Royal College of Music Royal College of Art

* College status:

Undergraduate Postgraduate Staff

* Department:

Health Questionnaire

* Height:

* Weight:

Physical Activities and Eating Habits:
Which best describes your normal EXERCISE pattern per week?
* Which best describes your normal DIET?
Do you think you have a problem with eating, involving restriction of foods, over eating or your eating overall?	Yes No
Have other people (for example, doctors, family members, significant others) noticed that you have a problem with eating?	Yes No
Do you make yourself sick because you feel uncomfortably full?	Yes No
Would you say that food dominates your life?	Yes No
Have your eating habits led to difficulty maintaining your weight?	Yes No
Are you or is anyone else worried about your weight?	Yes No
Has your weight significantly changed in the last 3 months?	Yes No
Any other information about your diet, eating habits or weight:

* Ethnic origin:	Other:
Religion:
1^st language:	Need interpreter:	Yes No

* Are you a carer?

* Do you have a carer?

* Do you have an advocate?

Yes No

Please tick if you have, or have had, any of the following ILLNESSES:

Asthma:	COPD:	Heart problems:	High blood pressure:
Diabetes:	Stroke/TIA:	Thyroid problems:	Mental health problems:

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 significant FAMILY HISTORY of illness including their relation to you:
Please list any DRUG ALLERGIES or ALLERGIC REACTIONS:

* Do you SMOKE? Yes No Used to smoke

How often do you have a drink that contains ALCOHOL?
Never (0)	Monthly or less (1)	2-4 times / month (2)	2-3 times / week (3)	4+ times / week (4)

* How many alcohol units per week do you drink?
NHS Alcohol Unit Calculator

How many standard alcoholic drinks do you have on a typical day when you are drinking?
1-2 (0)	3-4 (1)	5-6 (2)	7-9 (3)	10+ (4)

How often do you have 6 or more standard drinks on one occasion?
Never (0)	Less than monthly (1)	Monthly (2)	Weekly (3)	Daily or almost daily (4)

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 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 *

VACCINATIONS

Have you had a Measles Mumps and Rubella vaccine (MMR)?

Yes No

Have you had a Meningitis ACW&Y vaccine? Yes No More info...

Have you had HPV VACCINATION? Yes No
Indicate vaccine (if known): Cervarix Gardasil
First date:	Second date:	Third date:

COVID19 Vaccination

* Have you received the COVID-19 vaccination? Yes No

Please fill in DOSE(1,2,3), DATE and BRAND of vaccination and in which COUNTRY they were given:

WOMEN OVER 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.

Tuberculosis (TB) Screening Questionnaire

In an effort to detect latent TB (this is where you may carry TB but not be experiencing any symptoms) we recommend
that patients complete this short questionnaire to find out if you are eligible for a free TB screening blood test:

Are you aged between 16-35 years old?
Yes No

* NHS Medical 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.

Summary Care Record (SCR) - Your Summary Care Record is a short summary of your GP medical records. It tells other health and care staff who care for you about the medicines you take and your allergies. Please visit this site for more information on SCR and how to opt out.

NHS Records Amendment - Medical record sharing allows your medical record to be made available between your GP and other authorised health services involved in your care. You decide whether your medical record is shared out with other external health providers (e.g. hospitals, walk in centres) and whether your medical records from other health providers is shared with your GP. Your medical records are only accessed when it is necessary to provide services for you. Please indicate below your preference:

I wish for my medical record from external health providers to be shared with my GP:
Yes No

I wish for my medical record to be shared with external health providers:
Yes No

Research and Planning Data Collection - Your data can be used to help with research and planning. Please visit this site and this site for more information on how your data is used. If you would like to opt out of your data being used for this purpose then please complete the National Data Opt Out and the Type 1 Opt Out form. Further information on opting out of these services can be found in the links above.

* ONLINE SERVICES

The Health Centre offers online services for booking and cancelling appointments, ordering repeat medication, amending your contact details and viewing your medical record.’ Initially, only booking and cancelling appointments will be available. You can apply for the additional services by submitting the application form and personal identification documents as detailed on our website. For information on online services and how to use them safely please visit; https://www.imperialcollegehealthcentre.co.uk/health-centre/online-access/

* Would you like to sign up for online services to book and cancel appointments?
Yes No

We strongly recommend all our patients download the NHS App, where they will be able to access online services
as well as submit clinical and administrative queries: https://www.nhs.uk/using-the-nhs/nhs-services/the-nhs-app/

Patient/Practice Agreement for Imperial College Health Centre (please read this carefully)

We are committed to providing a warm welcome and excellent care to all patients in a calm and pleasant atmosphere. To this end, we propose the following agreement, which we hope will facilitate a good relationship between us and you.

The practice:

Aims to provide the highest quality of medical services possible, within the limits set by the NHS.
Will provide access to the practice doctors and nurses through a combination of electronic, video, booked face to face and telephone consultations, and walk-in triage clinics.
Will aim to consult with our patients for routine matters within two weeks. Consultations may be face to face, over the phone, or via e-consultations.
Expects practice staff to treat all patients in a courteous, caring and respectful manner regardless of age, ethnicity, disability, gender, sexual orientation, trans status, religion, belief and civil or family status.
Will attempt to attend to our patients needs as quickly as possible on arrival at the Health Centre.
Will provide a clean and safe environment for patients to wait and receive medical attention.
Will aim to keep to our appointment times. However, inevitably some medical problems do take longer than the allocated 10 minutes.
Will ensure that confidential medical information is protected and processed accordingly to latest NHS and data protection guidance.
Encourages patient feedback and should you wish to make a suggestion or complaint, we will provide information on how to do so, and will ensure that so doing does not compromise your medical care.
If you feel we have fallen short in these commitments then please let us know by contacting Jacquie O’Connor, Practice Manager.

We ask you, the patient:

To attend appointments punctually and inform us as soon as possible (preferably at least 24 hours in advance) if you need to cancel your appointment. If you are late for your appointment, you may be asked to rebook.
To treat Health Centre staff and other patients with courtesy and respect at all times.
To respect the comfort and wellbeing of others by refraining from using personal audio equipment and be considerate when talking on mobile telephones whilst in the Health Centre. Smoking and the consumption of alcohol, intoxicating or illegal drugs is strictly forbidden. Animals, other than registered assistance dogs, may not be brought into the Health Centre.
To not bring bikes, scooters or skateboards into the Health Centre.

Additional notes:

The practice reserves the right to remove patients who break this agreement from our patient list. Should removal take place, the patient will be informed why this has been done. The practice has a zero tolerance policy for physical and verbal aggression towards our staff and other patients. Any patient using threatening language and/or behaviour will be removed from the list and may be reported to either the police or appropriate college authorities. Patients who persistently fail to attend appointments, or cancel them in good time, will be removed from our list. We may contact you by letter, telephone, email or text message as appropriate. Please let us know if you prefer not to be contacted by any of these methods.
If you are completing this form on behalf of someone else you must have explicit consent or power of attorney from that person.

By submitting this application you are agreeing to the terms as detailed above and wish to register for general medical services.

Organ Donation

The law has changed so that you need to opt out if you do not want to become a donor. It’s
important to talk to your family about your organ donation decision, as they will be asked to
support your decision. If you are undecided or do not want to become an organ donor, please
refer to the NHS Organ Donation website at www.organdonation.nhs.uk or 0300 123 23 23.

Blood Donation

If you are interested in becoming an blood donor, please click this link
to go to the blood donor registration page.

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.