University of Essex Rowhedge & University of Essex Medical Practice
 

Registration for Rowhedge & University of Essex Medical Practice

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

Have you ever registered with this practice before?
Any student (+staff living on campus) can use this form to register.
Duration of Course: Years  &  Months
Non-EEA students studying on courses of 3 months' duration or less are not eligible to register.
* 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 at birth:  
 
* Select your new address from the list below if you are staying in University accommodation
House/Hall :
Floor/Block/House:
Room:
(if applicable)
(if applicable)
(if applicable)
or; Type in your new address below if you are not staying in University accommodation.
Please include flat and room number if applicable!




Enter your own telephone number. Preferably your mobile number

Enter your e-mail address
Confirm your e-mail address
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
Previous address in UK before going to University
*
*
*




* Approximate date of first living at this address: Date you first lived at this address


Part 2: Fill in if you come from abroad (international student)
Date you think you will leave UK

Date you left UK if you had registered with a GP before
Supplementary Questions:
Please select one of the following options: More information...
Complete the following section if you come from another EEA country: Information
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
 cm  kg
 
Current personal medical history
Have you currently any of the following?
    Are you on medication?
Last HbA1c (if known):    
   
Date of last fit:    
 
Past personal medical history
Have you ever had?
 
Family medical history
Has anyone in your family had?
   
 
Any other current and past MEDICAL /
SURGICAL / MENTAL HEALTH ISSUES
 
Please specify name of condition and
year of diagnosis (if known):
 
MEDICATION
 
Are you a CARER?  
 
SMOKING
* Do you smoke?
    
    
Would you like help to stop smoking?   
For help with stopping smoking, visit Essex Lifestyle Services
or call them on 0300 303 9988.
*
 
ALCOHOL
* 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 drinks on one occasion?
 
IMMUNISATIONS
If known, please complete your vaccination dates for:
   
     
 
ETHNICITY
   
 
* Summary Care Records
Summary Care Record (SCR) - this is an electronic record which contains information about the medicines you take,
allergies you suffer from and any bad reactions to medicines you have had. Having this information stored in one place
makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed.
    
 
* Enhanced Data Sharing Model
It is practice policy to share information that is recorded on your clinical record with other clinical staff that you are under
the care of to ensure the best care is provided to you. For further information please ask for an information leaflet
or visit www.nhscarerecords.nhs.uk/carerecords.
Do you consent for us to share your medical records with other medical service
you may be using i.e. District Nurse Teams, Podiatry or Dieticians?
    
 
May we CONTACT YOU via text message or email?
You can receive communications from your GP Surgery by email and phone, however you have to give consent for this.
This includes; appointment reminders, test results, messages relating to your specific health need e.g. a flu
vaccination reminder, general health information that could benefit you, information about emergencies etc.
Your phone number/email address will not be provided to third parties.
* May we contact you by email?
* May we contact you by SMS/text?
 
Do you have any SPECIAL REQUIREMENTS when attending appointments
(please tick) or please advise of any other:
 
 
FEMALES over 25
Do you wish to attend for cervical screening?   
Have you ever had a Cervical Smear (PAP Test)?   
  
 
Organ Donor Registration
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:
 
Blood Donor Registration
If you are interested in becoming an blood donor, please click this link to go to the blood
donor registration page, alternatively you can fill out the form below.
 
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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