Student Patient Registration (page 1 of 2)

Please fill in your details and click Next 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 Students’ Health Service to do so.
Please do not use this form to update your address or other details.

Please note - You must be an active registered Bristol University Student to register with this service.
Please tick this box to confirm that you are an active registered student of Bristol University:

* I am an active registered student of the University of Bristol:

* Student ID number:

* Department/Faculty:

* Subject:

* Year due to finish:

* Title:

Mr Mrs Miss Ms

Would you prefer your Title to appear as Mx,
instead of the title you have selected above?

Yes No

* Surname/Famly name:

* First name:

Middle name(s):

Calling name (if different from First name above):

Previous surname(s):

* Date of birth:

NHS No. (if known):

Gender:

Male Female

* Town and country of birth:

* Select your new Bristol address from the lists below if you are staying in Halls:
Halls of residence:
Room or Flat number:

* or: Type in your Bristol address below if you are not staying in Halls:
Address if not in uni Halls:

* Town:

* Postcode:

UK Mobile telephone number:

* E-mail Address:

University E-mail Address:

We find that SMS/text messaging and e-mail are often the most efficient methods of contacting patients about routine matters.
E.g. to remind you of an appointment. We may also use text messaging to send test results.

* Is it OK to contact you by SMS/text for test results? Yes No
* Is it OK for us to contact you by e-mail? Yes No

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:

UK Student
International Student

Part 2: Fill in if you come from the UK
* Previous Address in UK: (i.e. last address before going to University) Town: * Postcode:
Name of Doctor or Surgery when at that address:
Address of Doctor or Surgery: Postcode:

Part 2: Fill in if you come from abroad (international student)

* Date when you arrived in UK:

Your first UK address where registered with a GP:
(only if you have previously registered with a GP)
Town:
Postcode:

If you previously lived in UK, date of leaving:

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...

* Signature:

Clear

* Confirmation:

I understand that following completion of my studies at
Bristol University I will be removed from your list of
patients unless I advise you that I am remaining resident
in your practice area and wish to continue my registration.

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.