Lancaster University

Student Patient Registration for
Lancaster University Medical Practice

Lancaster Medical Practice
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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 Student Health Service to do so.
Please do not use this form to update your address or other details.

If you would like to book a New Patient Check please contact the Lancaster University Medical Practice on arrival at University.

* 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
* Gender:
 
Select your new University address from the list below if you are staying in University accommodation
* Address in Lancaster:
Select your university accommodation address in Lancaster from this list. Disregard if you are in other accommodations
or; Type in your new University address below if you are not staying in University accommodation 
Your address in Lancaster if you are not in university accommodation. NOT your old home address
Enter your own telephone number. Preferably your mobile number
* E-mail address: Enter your e-mail address
* Confirm E-mail address: Confirm your e-mail address
How would you prefer to be contacted?      
Do you have any communication needs?      
  
Enter the length of your course at university
*  Select the practice you want to be registered with
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




Part 2: Fill in if you come from abroad (international student)
* Date when you arrived in UK:


If you previously lived in UK, date of leaving:
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
   
Current and past MEDICAL / SURGICAL /
MENTAL HEALTH CONDITIONS
 
Please specify name of condition and
year of diagnosis (if known):
Please give details of any ALLERGIES
you have:
* Do you SMOKE?
    
    
For help with stopping smoking, please visit www.smokefree.nhs.uk or text TXTHELP to 63818.
In addition, the number for the local Smoking cessation helpline is 01524 845145
   
 Alcohol units. Enter 0 if you don't drink.  NHS Alcohol Unit Calculator
How often do you have a drink that contains alcohol?
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?
 
Organ Donation
If you are interested in becoming an organ donor, please click this link to go to the organ donor
registration page, alternatively you can fill out the form below.
I would like to join the NHS Organ Donor Register as someone whose organs may be
used for transplantation after my death.
Please tick as appropriate:
 
Important Information:
It is practice policy to share information that is recorded on your clinical record with other
NHS clinical staff who you are under the care of, to ensure the best care is provided to you.
For further information please visit www.nhscarerecords.nhs.uk/carerecords
 
Please note: The information you are submitting will be passed to the medical centre over the Internet which is not 100% secure. If you are worried about this you can instead obtain a form from the surgery which can be filled in and delivered by hand.
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