Langworthy Medical Practice

Langworthy Medical Practice
Online Registration

University of Salford
It's very important that you register with a local GP practice. Once registered we can:
  • Get hold of your medical history as soon as possible
  • Send information to you on relevant health issues
  • Pick up on any ongoing medical problems
  • Sort out any prescriptions you need to request
But most importantly, it will be the place you know to go when you are ill, and the place they know about you!

Please do NOT use this form to update your address or contact details.

Please fill in your details and click Submit 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 by the Medical Practice to do so.

* Have you ever registered
with this practice before?
* Title:       
Please enter all your first names in full
 If you don't know your NHS number it's very important that you fill in part 1 and 2 below Please contact your previous surgery
to get your NHS number. Failure to do
so can slow down your registration.
* Gender assigned at birth:  
* Gender identity: Other:
Would you like to be known as the alternative Title
of "MX", as opposed to your selection above?
* Sexual orientation: Other:
Marital status:
Religion/Belief: Other:
Enter your own telephone number. Preferably your mobile number

Enter your e-mail address
Confirm your e-mail address
Do you give consent for us to CONTACT YOU via text message or email?
* Text/SMS:
                 * Email: 
You are giving permission for us to send you appointment reminders, information regarding  your health care and clinic updates.
How would you prefer to be contacted?
* Do you have any caring responsibilities for a child or children under 18?    
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
Previous address in UK before registering here:

Part 2: Fill in if you come from abroad
* Date when you arrived in UK:
* Expected date of leaving UK: Date you think you will leave UK
Have you lived or studied in the UK Before?  
Supplementary Questions:
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
Who would you like us to contact if there is a medical emergency?

If you are attending university for the first time and are aged 24 and under, you should, if possible, ensure that you
have received Meningitis ACWY and MMR (Measles, Mumps, Rubella) vaccines prior to commencing your studies.
Have you ever had the following vaccinations?
Meningitis ACWY:
1st MMR vaccine:
2nd MMR vaccine:
 cm  kg
Female patients over the age of 25 are eligible for CERVICAL SCREENING
Have you had a cervical screening?   
What's your DIET like?
Do you look after a relative, friend or neighbour who cannot manage
without your help due to sickness, age or disability?
Are you a carer?     
Are you an ARMED FORCES VETERAN?      
Do you have any of the following MEDICAL CONDITIONS?    (Please tick and enter onset date)
Any other current and past MEDICAL /
Please specify name of condition and
year of diagnosis (if known):
Please give details of any DISABILITY:
Are you Registered BLIND or DEAF?   
Please indicate if you require any of the following Communication Services:
* Do you smoke?
What did you smoke?           
What do you smoke?           
For help with stopping smoking, visit This Link
The number for the local Stop Smoking Service is 0800 952 1000
* 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
Do you consider yourself to be suffering from anxiety or low mood?     

Interpreter required?   
Are you currently a Refugee or Seeking Asylum in the UK?

* Summary Care Records
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.
* Important Information
It is practice policy to share information that is recorded on your clinical record with other clinical staff that you are under
the care of to ensure the best care is provided to you. For further information please ask for an information leaflet
or visit
Your record will be automatically setup to be shared with the other Health Care organisations. These organisations
will only be able to view your shared record if they are actually providing you with care. However, you have the right
to ask your GP to disable this function or restrict access to specific elements of your record.  This will mean that
the information recorded by your GP will not be visible at any other care setting
Do you consent for us to share your medical records with other medical service
you may be using i.e. District Nurse Teams, Podiatry or Dieticians?
Would you like to have access to the following online services?
Booking appointments:     
Request repeat prescriptions:  
Organ Donor Registration
If you are interested in becoming an organ donor, please click this link
to go to the organ donor registration page.
Blood Donor Registration
If you are interested in becoming an blood donor, please click this link
to go to the blood donor registration page.
Please read the CampusDoctor 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.
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