Goldsmiths University of LondonAmersham Vale Practice

Amersham Vale Practice         
Student Patient Registration (page 1 of 3)

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

Study course at university
* Approximate finish date of course:  When does your course finish?
   
* 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:
 
Please select your hall address from the list below and add your room/flat number
or
please enter your complete address while studying here
:
  Select your halls of residence from this list
Enter your own telephone number. Preferably your mobile number
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 Uni/College)

*




Part 2: Fill in if you come from abroad (international student)
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...
Your e-mail address
Confirm your e-mail address
* Signature:
Please draw your unique signature in the box
By ticking this box I confirm that I have filled
in this form to the best of my knowledge
and signed it with my own unique mark.
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..
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