Leeds Student Medical Practice
Online Registration

CAN YOU REGISTER?
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?

Yes No

University or College:

Course title or department:

Or: Tick this box if you are the partner
or child of a registered student:

Please go to the practice with a guardian to register in person if you are under 16.

* Title:

Mr Mrs Miss Ms

* Family/Surname:

* First name(s):

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:

Previous First name(s):

Previous Surname(s):

* Date of birth:

NHS No. (if known):

* Gender:

Male

Female

Please select a gender as we need this
to find your previous medical records.

Marital status:

Single Married Prefer not to say

* Religion/Belief:

Buddhist Christian Hindu Humanist
Jewish Muslim Sikh Agnostic Atheist
No religion Prefer not to say Other:

* Country of Birth:

...

Please fill in your new ADDRESS in Leeds or select your accommodation from the list

Accommodation:

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

Room or Flat:

House/Hall Name:

* House Number and Street Address:

* Town:

* Postcode:

* Mobile telephone number:

* Email address:

* Confirm Email address:

IMPORTANT

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:

Yes No

* Email:

Yes No

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:

UK Student
International Student

Part 2: Fill in if you come from the UK
* Are you currently living in Leeds?	Yes No
* Planned date of arrival 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.
* Previous Address in UK: (i.e. the address your current GP will have for you) * Town: * Postcode:
* Name of Doctor or Surgery when at that address:
* Address of Doctor or Surgery: Postcode:

* Are you currently in the UK?

Yes No

You cannot register with us until you are in the UK

Part 2: Fill in if you come from abroad (international student)

* Date when you arrived in UK:

How many months will you stay in the UK?

Biometric Residence Permit (BRP) Number:

International home address:

Apartment/house number:

Street Name:

City:

State/Province:

Country:

ZIP/Postal Code:

Have you lived or studied in the UK before?

Yes No

Supplementary Questions:

Please select one of the following options: More information...

	I understand that I may need to pay for NHS treatment outside of the GP practice
	I understand that I have a valid exemption for paying for NHS treatment outside of the GP Practice. I can provide documents to support this when requested This includes for example, an EHIC, or payment of the Immigratin Health Charge ("the Surcharge"), when accompanied by a valid visa.
	I do not know my chargeable status

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? Yes No

Tick here if you have an S1
(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:

Clear

Health Questionnaire

	* Ethnic origin:		Other:
	* 1^st language:		Need interpreter:	Yes No

* Is your gender the same as you were assigned at birth?

Yes No

* Which of the following best describes you?

Man (including trans men) Woman (including trans women)

Non-binary Prefer not to say Other:

* Which of the following best describes how you think of yourself?

Heterosexual/Straight Gay/Lesbian

Bisexual Prefer not to say Other:

SERIOUS ILLNESS, OPERATIONS OR DISABILITIES Please tell us if you have or have had any significant medical condition. For each item please tell us the year the event happened or when the problem started. (E.g. Mental Health Problems, Inflammatory Bowel Disease, Asthma, Diabetes, Arthritis, Epilepsy, Cancer, Transplant, Hearing or Sight Disabilities):
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? Yes No

Please record any DISABILITIES here:

Do you have any special communication needs?

Yes No

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?	Yes No
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)?

I am a full time carer

I am a part time carer (includes caring responsibilities during university vacation)

I am not a carer

COVID Vaccine Information

* Have you received the COVID-19 vaccination? Yes No

NAME of first vaccine:		NAME of second vaccine:
Other name:		Other name:
COUNTRY first vaccine given in:		COUNTRY second vaccine given in:
DATE first vaccine given:		DATE second vaccine given:

NAME of third vaccine:		NAME of booster vaccine:
Other name:		Other name:
COUNTRY third vaccine given in:		COUNTRY booster vaccine given in:
DATE third vaccine given:		DATE booster vaccine given:

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:

Please list any DRUG ALLERGIES
or ALLERGIC REACTIONS:

Please list any CURRENT MEDICATION, including inhalers.
Please specify name, dose and freqency:

	* Name:
EMERGENCY CONTACT	* Phone no:
	* Relationship:

* Height:

* Weight:

* Do you SMOKE? Yes No Used to smoke

* Amount you used to smoke per day:

When did you stop?

* 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

* Tick here to confirm that you have read the information above:

EXERCISE - In an average week how often do you take exercise which leaves you
mildly out of breath, and makes you perspire slightly?

No regular exercise

Less than 1 hour of physical exercise each week

More than 1 hour but less than 3 hours of physical exercise each week

More than 3 hours of physical exercise each week

How often do you have a drink that contains ALCOHOL?
Never (0)	Monthly or less (1)	2-4 times / month (2)	2-3 times / week (3)	4+ times / week (4)

* How many alcohol units per week do you drink?

NHS Alcohol Unit Calculator

How many standard alcoholic drinks do you have on a typical day when you are drinking?
1-2 (0)	3-4 (1)	5-6 (2)	7-9 (3)	10+ (4)

How often do you have 6 or more standard drinks on one occasion?
Never (0)	Less than monthly (1)	Monthly (2)	Weekly (3)	Daily or almost daily (4)


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?
Never (0)	Less than monthly (1)	Monthly (2)	Weekly (3)	Daily or almost daily (4)

How often during the last year have you failed to do what was normally expected from you because of your drinking?
Never (0)	Less than monthly (1)	Monthly (2)	Weekly (3)	Daily or almost daily (4)

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?
Never (0)	Less than monthly (1)	Monthly (2)	Weekly (3)	Daily or almost daily (4)

How often during the last year have you had a feeling of guilt or remorse after drinking?
Never (0)	Less than monthly (1)	Monthly (2)	Weekly (3)	Daily or almost daily (4)

How often during the last year have you been unable to remember what happened the night before because you had been drinking?
Never (0)	Less than monthly (1)	Monthly (2)	Weekly (3)	Daily or almost daily (4)

Have you or somebody else been injured as a result of your drinking?
No (0)	Yes, but not in the last year (2)		Yes, in the last year (4)

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?
No (0)	Yes, but not in the last year (2)		Yes, in the last year (4)

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.
I have read the information regarding SCR and wish to opt-out (not to have an SCR):
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.
If you would be happy to be contacted regarding the patient participation group please tick here:

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.

Accessing your Medical Records online

* Would you like to Opt-In or Opt-Out of accessing your medical records online?

Opt-in Opt-out

You can always Opt-in or Opt-out at a later stage by visiting the practice in person.

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.

Leeds Student Medical Practice Online Registration

You cannot register with us until you are in the UK

Leeds Student Medical Practice
Online Registration