Registration for the University of Nottingham Health Service

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. Use THIS FORM instead
to update your address or other details if you are already registered with us.

Name of course (if relevent):

Length of course (if relevent):

* Title:

Mr Mrs Miss Ms

* Family Surname:

* All first names:

Previous surname/s:

* Date of birth:

NHS Number (if known):

* Gender:

Male Female Other

Preferred pronouns:

Would you prefer your title to be "Mx",
instead of the title selected above?

Yes No

* Country of birth:

Please enter UK Country (England, Scotland, Wales
or Nothern Ireland) if from UK., e.g. "London, England"

Nottingham Address.

If you live in student accommodation, please select your address and flat from the lists below:

Student Accommodation:

Flat/Apartment:

If you don't live in student accommodation, please enter your complete address below:

Flat & Hall/House:

* Street:

Area:

* Town:

* Postcode:

* Mobile phone number:

* Email address:

* Confirm email address:

* May we contact you using email?

Yes No

* May we contact you using SMS text?

Yes No

Please help us trace your medical records by selecting if you are a UK or International
patient (Part 1) and then filling in the next section (Part 2)

* Part 1. Select if you are from UK or abroad:

UK patient
International patient

Part 2: Fill in if you come from the UK

Previous address in UK before moving here

* Previous UK address:

* Town:

* Postcode:

* Name of Doctor or Surgery when at that address:

* Address of Doctor or Surgery:
Postcode:

Please tick this box if you are NOT a student:

* Signature:

Clear

ETHNICITY
* Ethnic Group:		Other:
* Your first language:
* Do you need an interpreter?	Yes No

* HEIGHT:

* WEIGHT:

* Are you a CARER?	Yes No
	* If yes, who do you care for?

CERVICAL SCREENING

If you are over 25 and you were recognised as female at birth, you are eligible for
free cervical screening and will be included in the national screening programme.
If you are unsure about screening, please read the information in this link.

After reading, if you wish to decline cervical screening, please tick the box below.

I have read the information regarding cervical screening and have
made an informed decision to decline cervical screening at this time:

I understand that if I change my mind, I can be included again at any time.

Organ Donor Registration

Organ donation in England has changed to an 'opt out' system. You still have a choice
about whether or not you wish to become a donor and your faith, beliefs and culture
will continue to be respected. You can record your organ donation decision on the
NHS Organ Donor Register. Tell your family and friends what you have decided.

Blood Donor Registration

If you are interested in becoming an blood donor, please click this link
to go to the blood donor registration page.

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.