THIS IS NOT A REAL REGISTRATION

Student Patient Registration for a University Health Centre

Please fill in your details and click Submit when complete.

An 8-digit number supplied by UWE
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 will slow down your registration.
Gender:
 
Please fill in this section if you are going to stay in University Accommodation
  Address in Bristol:
(university accommodation)
Select your university accommodation address in Bristol from these lists. Disregard if you are in other accommodations
Please fill in this section if you are not going to stay in University Accommodation
Postcode:
(fill in your new postcode and click Find Address)

Your address in Bristol if you are not in university accommodation. NOT your old home address
Enter your own telephone number. Preferably your mobile number
Enter a person (full name including surname) we should contact in case of an emergency
Enter your relationship to the emergency contact
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
(i.e. last address before going to UWE)






Part 2: Fill in if you come from abroad (international student)
You can't register before you arrive in the UK
(only if you have previously registered with a GP)




A confirmation message will be sent to this address.
Your test GMS1 form will be sent to this address instead of the practice
Signature:
Please draw your unique signature in the box
   
Health Questionnaire
   
Please list any EXISTING OR PAST SIGNIFICANT MEDICAL CONDITIONS:
Please list any CURRENT MEDICATION, including inhalers. Please specify dose:
Do you SMOKE?
    
    
For help with stopping smoking, please visit www.smokefree.nhs.uk or text TXTHELP to 63818.
In addition, the Old School Pharmacy in Fishponds runs smoking cessation clinics, and can be
contacted by phone on 0117 9651114 and by email at oldschoolpharmacy@nhs.net
How often do you have a drink that contains alcohol?
  Please enter a number 
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?
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:
Please note: The information you are submitting will be passed to the Surgery 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.

THIS IS NOT A REAL REGISTRATION

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