St Edmund Hall Registration

Title:

Surname: *

First Name (S): *

Previous Surname:

Birth Town: *

Birth Country: *

Telephone:

Date Of Birth: *

NHS Number (if previously registered with NHS):

Sex *

Male

Female

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Your Previous Address In The UK

Name of previous GP while at your previous address

Address of that Doctor

If you are from abroad please provide the following information:

Your first UK address where registered with a GP

If previously resident in UK, date of leaving

Date you first came to live in UK

If you are returning from the armed forces please provide the following information:

Address before enlisting

Service/Personnel No.

Enlistment date

Signature

Signature Of Patient

Signature On Behalf Of Patient

Signature

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Summary Care Record and Oxfordshire Care Summary – Your Choice

We recommend opting into Oxfordshire care summary records

Your choice for Summary Care Record *

I wish to share my information

I DO NOT wish to share my information

I wish to share my information WITH additional Information

I DO NOT wish to share my information WITH additional Information

Your choice for Summary Care Record

Your Choice for Oxfordshire Care Summary and the Out-of-Hours GP records sharing system (local NHS system) *

I wish to share my information

I DO NOT wish to share my information

It is important to complete this information as your new practice cannot make a decision for you. Without your direction, we cannot guarantee that your wishes will be met, even if you have previously made a similar choice in another practice.

If the person signing below is not the patient, please also enter the signatory’s name and relationship to the patient, e.g. PARENT, GUARDIAN, ATTORNEY

Full Name

Relationship to patient

Signature

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Contact Details
We would like to be able to contact you by email and text on matters regarding your health or to text you reminders about your appointments. If you are happy for us to contact you in this manner please provide your email and mobile telephone number:

UK mobile (cell) number

Email address

Course subject

Address & telephone during vacations

Are you a post graduate student?

Yes

No

If yes please provide Oxford address, if unable please provide as soon as possible

If not please provide your term time address

Name and contact details of next of kin *

Name of doctor during vacation

If you need to be seen by a doctor at home during vacation, please register as a TEMPORARY RESIDENT. If you register as a normal patient you will be removed from our patient list and will need to re-register with our practice on your return to college.

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Have you ever suffered from (tick as appropriate)

If other please provide details

Are you currently under medical care of any sort?

Yes

No

If yes, please provide details

Do you suffer from any allergies, e.g. Penicillin, cats, etc.

Yes

No

If yes, please provide details

Are you taking any regular medication? Please include inhalers, creams, contraception, etc.

Yes

No

If yes, please provide details

Do you smoke? *

Yes

Ex-smoker

Never smoked

If ex-smoker please provide date stopped

If you are a smoker would you like help to stop?

Yes

No

If you are over 25, have you had a cervical smear test?

Yes

No

If yes, please provide test date and result

Do you drink alcohol? *

Yes

No

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 alcoholic drinks on one occasion? *

What is your present weight (please specify if kg or lb)? *

How tall are you (please specify if metres or feet & inches)? *

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It is a university of Oxford requirement that all students have had MMR and Meningitis ACWY Vaccinations before commencing their courses.

If you are unable to get these vaccinations before coming to Oxford, then we are able to provide these on registration date.

Have you been vaccinated against measles/mumps/rubella (MMR)?

Yes

No

Please provide date(s) of vaccination

Have you been vaccinated against meningitis ACWY?

Yes

No

Please provide date(s) of vaccination

End Section

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What is your main language?

Do you need an interpreter or sign language support?

Yes

No

What is your Ethnic Group

Other - please specify

Thank you for completing this registration form. When your form is complete please press the submit button. Your registration form will be sent to the Practice. We will register shortly before you are due to start at your college.

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End Section

If you wish to, you can now use the internet to book appointments with your GP and request repeat prescriptions for any medications you take regularly.

If you wish to use this service, please complete the details below and we will email your log in details to you.

Access to GP online services. I wish to have access to the following online services (tick all that apply):

Booking appointments

Requesting repeat prescriptions

0 I am happy to have my access information emailed to me at the email address provided in my registration form. I understand this may not be secure and accept this risk.

Name

Time

You can also view your medical record online. This can help you manage your medical conditions. It also means you can access it from anywhere in the world should you require medical treatment on holiday.

If you wish to sign up for medical record viewing, you will need to present at the practice to complete the appropriate form and to present proof of identification in the form of a passport or photo card driving license.

It will be your responsibility to keep your login details and password safe and secure. If you know or suspect that your record has been accessed by someone that you have not agreed should see it, then you should change your password immediately.

Summertown Group Practice

Immunisation History

Ethnicity & Language Questionnaire

Contact Details