Leeds Student Medical Practice
Online Registration

To register at Leeds Student Medical Practice:
You must be a student (or partner / child of a student) at a university / college / educational
facility AND live in: university accommodation in Leeds or private accommodation in the
following post code areas: LS1 to LS7, LS16 South of the Ring Road, Marsh Lane and
Regent Street areas of LS9 and LS10.

Please don't register until you know your full address because it may fail if your address is incomplete.

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

Have you ever registered
with this practice before?
 Please go to the practice with a guardian to register in person if you are under 16.
* Title:
Please enter your surname or family name
Please enter your first name
If you have ever been known by another name whilst living in the UK
please enter it here to help us find your medical records:

 If you don't know your NHS number it's very important that you fill in part 1 and 2 below  
* Gender:
Please select a gender as we need this
to find your previous medical records.
Marital status:      
* Religion/Belief:
Please fill in your new ADDRESS in Leeds or select your accommodation from the list
Select your accommodation in Leeds from this list. Disregard if you are in other accommodations.
Please don't register until you know your full address because it may fail if your address is incomplete.
Enter your own telephone number. Preferably your mobile number
We may need to contact you from time to time about your personal healthcare – for example to inform you of important
test results, upcoming appointment reminders or when you need review of ongoing medical problems.  
We will usually do this by SMS text messages, email, telephone calls or letter.
We find SMS messages and Email are the most reliable forms of contact and would like your consent to use these methods to contact you.
We will NOT use any of your contact details for marketing.
We will only share your details under strict conditions that are detailed in our Privacy Notice (download PDF version).
Please indicate your consent for use of SMS Messages and Email to support your healthcare below:
I consent for Leeds Student Medical Practice to contact me regarding matters directly relating to my healthcare by:
* SMS Text:    
* Email:    
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
Are you currently living in Leeds?    
Planned date of arrival in Leeds: When do you plan to arrive in Leeds?
Please note that you won't actually be registered with the Student Medical Practice until you arrive in Leeds.
Before then you will still be registered with your old practice.
(i.e. the address your current GP will have for you)

* Are you currently in the UK?   

You cannot register with us until you are in the UK

Part 2: Fill in if you come from abroad (international student)
You can't register before you arrive in the UK
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
  * Ethnic origin:  
  Need interpreter:     
* Is your gender the same as you were assigned at birth?
* Which of the following best describes you?
* Which of the following best describes how you think of yourself?
We will need to contact your hospital Consultant and/or previous GP to confirm treatments/medications
before we can prescribe them for you. This is so we can make sure the correct medication information
is entered into your Electronic Health Record for repeat prescription requests.
Please provide hospital name and address and name of Consultant you normally
see, or if you only see a GP, previous GP name and surgery address:
If under care of a Consultant, approximate date you last saw them:  
* Do you agree that Leeds Student Medical Practice can contact your hospital
and/or GP to ask them to confirm your current medical problems
and treatment/repeat medication requirements?
Do you have any special communication needs?   
The Accessible Information Standard aims to ensure that patients (or their carers) who have a disability or
sensory loss can receive, access and understand information, for example in large print, braille or via email,
and professional communication support if they need it, for example from a British Sign Language interpreter.

This applies to patients and their carers who have information and / or communication needs relating to a
disability, impairment or sensory loss.  It also applies to parents and carers of patients who have such
information and / or communication needs, where appropriate.

Individuals most likely to be affected by the Standard include people who are blind or deaf, who have
some hearing and / or visual loss, people who are deaf blind and people with a learning disability.
However, this list is not exhaustive.
Do you have any communication needs as explained above?   
Thank you, we will send you a form by email to enable you to give us more
detail of your requirements. Please complete this and bring it to reception
on your first visit to the Medical Practice.
* Carer Information
Are you a carer (someone who is looking after a family member, partner
or friend who needs help because of illness, frailty or disability)?
COVID Vaccine Information
* Have you received the COVID-19 vaccination?   
DISCLAIMER: LSMP are recording this information to assist with determining eligibility for future COVID-19 vaccination programmes. Your
GP-held records will NOT be coded to reflect you have been given the vaccines declared above. This information will NOT act as a COVID-19
pass for travel/event entry/as required. Depending on your responses, LSMP may contact you to provide further evidence of your declaration.
INFLUENZA VACCINATION - The practice recommends that patients with certain serious Illnesses are given an
Influenza vaccination every year. Please speak to reception if you would like to have an Influenza vaccination.
If you do NOT wish to have an Influenza vaccination please tick this box:
Enter a person (full name including surname) we should contact in case of an emergency
Enter a phone number to the emergency contact
Enter your relationship to the emergency contact
 cm  kg
* Do you SMOKE?     
* Amount you smoke per day:    
For help with stopping smoking, please visit www.smokefree.nhs.uk or text TXTHELP to 63818.
Or for local help, Leeds smoking cessation service contact details: Freephone 0800 169 4219,
Text: SMOKEFREE to 60066, Email: stopsmokingleeds@nhs.net, Website Leeds Stop Smoking Service
EXERCISE - In an average week how often do you take exercise which leaves you
mildly out of breath, and makes you perspire slightly?
How often do you have a drink that contains ALCOHOL?
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?
If your total alcohol score above is high it may indicate hazardous or harmful drinking.
Please then complete the more detailed questions below (score in brackets):
How often during the last year have you found that you were not able to stop drinking once you had started?
How often during the last year have you failed to do what was normally expected from you because of your drinking?
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?
How often during the last year have you had a feeling of guilt or remorse after drinking?
How often during the last year have you been unable to remember what happened the night before because you had been drinking?
Have you or somebody else been injured as a result of your drinking?
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?
Your alcohol score is: 0
0 – 7: Lower risk, 8 – 15: Increasing risk, 16 – 19: Higher risk, 20+: Possible dependence
Further information can be found in the Alcohol section of our website.
Summary Care Records (SCR) and Leeds Care Records (LCR)
The NHS in England has introduced the National Summary Care Record, and Leeds has introduced a Local Leeds Care Record. The record will contain information about your health. This will ensure those caring for you have enough information to treat you safely. Both records are kept securely on computers separate from the medical record Leeds Student Medical Practice will keep for you. Both records are created for you by default unless you choose to opt out.
For more information about NHS sharing you can talk to the Patient Advice and Liaison Service (PALS) on 0800 0525 270 or visit www.nhscarerecords.nhs.uk
You can choose not to have a Summary Care Record or Leeds Care record and you can change your mind at any time. If you do nothing we will assume that you are happy with these changes and create a Summary Care Record for you and a Leeds Care record.
Children under 16 will automatically have a Summary Care Record created for them unless their parent or guardian chooses to opt them out. If you are the parent or guardian of a child under 16 and feel that they are old enough to understand, then you should make this information available to them.

To opt out of Leeds Care Record you must telephone 0113 2064 102
Leeds Student Medical Practice has a Patient Participation Group where patients can give their views and
feedback on the services provided by Leeds Student Medical Practice and suggest improvements.
Organ Donation
The English organ donation law has changed in, 20 May 2020. All Adults in England are now considered to have
agreed to be an organ donor when they die unless they have recorded a decision not to donate or are in one
of the excluded groups. To become a registered donor or refuse on becoming a donor, please click this link.
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.
* = Compulsory.
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