Online Patient Registration

St Edmund Hall

Only accepted students and their dependants accompanying them to University
can use this form, and all names are cross-checked.
Please fill in your details and click "Next page" when complete (page 1 of 2). * = 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.

Degree:

(e.g. BA, MSc, DPhil etc)

* Expected Graduation Date:

Subject:

* Title:

Mr Mrs Miss Ms

* Family Surname:

* First name:

Any Middle names:

Preferred/Called name:

Previous surname/s:

* Date of birth:

NHS Number:

The NHS number is essential if you have been treated by the NHS
before. Contact your previous surgery to get your NHS number.

* Gender:

Male Female Other, please give details:

* Gender at Birth:

Male Female

* Town and country of birth:

The default address below is your College address.
If you have another Oxford address, please use the College address and inform the practice once you're registered.

Address in Oxford:

(college / hall / house name)

* (street address)

* Town:

* Postcode:

* Planned DATE of arrival in Oxford accommodation:

UK Mobile telephone number:

* E-mail Address:

* Confirm e-mail Address:

Please help us trace your medical records by selecting if you come from the 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:

I come from the UK
I come from abroad

Part 2: Fill in if you come from abroad

* Date when you arrived in UK:

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...

* Ethnic origin:

Main language:

	Other:
	Need interpreter?	Yes No

EMERGENCY CONTACT

* Full Name (including title):

* Telephone (incl national & area codes)
or Email address:

* Relationship:

* Are you happy for us to discuss your medical records with this person? Please consider your answer as this may impact on information shared.	Yes No
* Is the Emergency Contact also your Next of kin?	Yes No

* 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.

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.