The information you are submitting will be sent encrypted to
the medical practice over the Internet, which still isn't
you ever registered
with this practice before?
Mr Mrs Miss Ms Mx Other:
* Date of birth:
NHS No. (if known) :
Male (incl trans men)
Female (incl trans women)
* Do you identify as
* 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
Kemp Porter Buildings
Prince Consort Village
The Costume Store
Wood Lane Studios
number (UK only):
* E-mail address:
* Confirm e-mail address:
* May we contact you using email?
* May we contact you using SMS text?
* Preferred contact method:
Full name: *
* Phone 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:
Royal College of Music
Physical Activities and Eating
Which best describes your normal
EXERCISE pattern per week?
* Which best describes your normal DIET?
Please tick if you have, or have had,
any of the following ILLNESSES:
any other existing or past
SIGNIFICANT MEDICAL CONDITIONS
including major operations and dates:
any CURRENT MEDICATION,
inhalers and contraception. Please specify dose:
list any significant
FAMILY HISTORY of illness including
their relation to you:
any DRUG ALLERGIES
or ALLERGIC REACTIONS:
* Do you SMOKE? Yes
Do you have a
Disability or Special Communication Needs? Yes
Have you had a Measles Mumps and Rubella
Have you had a Meningitis ACW&Y
* 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:
I wish for my medical record to be shared
with external health providers:
Research and Planning Data Collection - Your data can be used to help with
research and planning. Please visit
this site and
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;
you like to sign up for online services to book and
cancel appointments? Yes
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:
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.
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
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
Will provide a clean and safe environment
for patients to wait and receive medical
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
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
If you feel we have fallen
short in these commitments then please let us
know by contacting Jacquie O’Connor, Practice
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
To not bring bikes, scooters or skateboards
into the Health Centre.
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.
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.
If you are
interested in becoming an blood donor,
please click this link
to go to the
blood donor registration page.
Please read our