Student Patient Registration
for Clarence Medical Centre

Please fill in your details and click Submit when complete.

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 Medical Centre to do so.
Please do not use this form to update your address or other details.

Have you registered with us before?
* (dd/mm/yyyy)
* (dd/mm/yyyy)
* Title:

(as found on passport)
Please enter your surname or family name
Please enter your first name
* Gender:    

For example: "London, England" or "Beijing, China"
Please select your accommodation or fill in your Egham area ADDRESS when at University
  University Hall:
(essential if in university accommodation)

This must be an address either on campus or in the Egham area with a postcode starting TW20.
A confirmation message will be sent to this address.
Enter your own telephone number. Preferably your mobile number
UK Number must start with 0 or + (not 00 or +0) and then
10-12 digits. Example: 07848293331 or +447848693431
Remember to update the surgery,,
when you get or change your UK Mobile Number.
We find that SMS/text messaging and email are often the most efficient methods of contacting patients about routine
matters e.g. to remind you of an appointment. We will never use text or email to send confidential medical information.
* May we contact you by email?
* May we contact you by SMS/text?
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 university)

Part 2: Fill in if you come from abroad (international student)
You can't register before you arrive in the UK
If you have a study visa, when does it expire?
Have you lived or studied in the UK before?    
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
  Enter a person (full name including surname) we should contact in case of an emergency
EMERGENCY CONTACT  Enter a phone number to the emergency contact
  Enter your relationship to the emergency contact
 cm  kg
  * Ethnic origin:  
  Need interpreter:     
Please tick if have, or have had, any of the following CONDITIONS:
* Do you SMOKE?
* How often do you have a drink that contains ALCOHOL?
  A number of alcohol units per week 
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.
Please read our Privacy Notice.
The information you are submitting will be sent encrypted to the medical centre over the Internet, which still isn't 100% secure.
If you are worried about this you can instead obtain a form from the medical centre that can be filled in and delivered by hand.
* = Compulsory.
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