GP Registration Form

University of Southampton
GP Online Registration

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 Health Service to do so.
If you are unsure of your registration status, you can contact the practice who will be able to confirm this for you.  

Current patients: DO NOT use this form to update your address or other details.

Have you ever registered
with this practice before?
*
*  
* Title:
Please enter your surname or family name
Please enter your first name
 If you don't know your NHS number it's very important that you fill in part 1 and 2 below
* Gender:  
Please enter your new ADDRESS in Southampton
 or select your accommodation from the list, if you live in halls
Select your university accommodation from this list. Disregard if you are in other accommodations.
Enter your own telephone number. Preferably your mobile number
We operate a system of appointment reminders via text message.
* Please either opt in or out of this service (if you've entered a phone number):
Please help us trace your medical records by selecting if you are from the UK or International
(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. 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:   
* Have you lived in another country for 6+ months in the last year?   
   
 
IMMUNISATIONS

You are strongly advised to ensure you are fully immunised to UK Department of Health standards.

Please note: We provide ALL NHS immunisations for FREE.

There is an increased risk of Meningitis, Measles, Mumps and Rubella due to the large numbers of students in the close
confines of a university campus, therefore it is important that you are vaccinated to protect both yourself and others
.
Please indicate if you have/have not had the following:
* Meningitis ACWY vaccine:
* 1st MMR (measles, mumps, rubella) vaccine:
* 2nd MMR (measles, mumps, rubella) vaccine:
 
Have you been diagnosed with any of the following CONDITIONS?

Please book an appointment with one of our doctors
if you have any of the conditions above.
 
Have you had/do you suffer from any serious ILLNESS?    
Have you had any significant INJURIES or OPERATIONS?    
Do you have any DISABILITY/COMMUNICATION needs?    
Do you suffer from any ALLERGIES?    
Do you take any prescribed MEDICATION at present?    
(including the pill and depo-injections)
Patients are required to see a doctor for the first time a prescription for long-term medication is requested from us.
Make an appointment BEFORE your next repeat prescription is due. Thereafter, if it is
appropriate for you to receive repeat prescriptions the following points should be noted;
 
1. Request your repeat medication at least 1-2 weeks before you run out (in case an appointment is required)
2. It takes a maximum of 2 working days for repeat prescriptions to be processed
3. You will be required to see a doctor from time to time to review your condition and medication
 
Do any of your parents/brothers/sisters suffer from any of the following medical problems:
 
 
     
 
* Do you SMOKE?     
* Amount you smoke per day:  
For help with stopping smoking, please visit http://www.quit4life.nhs.uk/ or call 0845 602 4663.
Alternatively, most pharmacies run smoking cessation clinics.
*
 
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
If your score is 8 or more, your answers suggest you may be at increased risk of future harm to your health from drinking.
Further information about this can be found at www.drinkaware.co.uk/alcohol-facts/alcoholic-drinks-units/how-much-is-too-much
* Tick here to confirm that you have read the above:
Females only
Have you ever been sexually active?  
Do you require contraception?  
  If you require the contraceptive pill, you will need to see a doctor at
the health service in the first instance to get this set up and issued. 
Thereafter you can use our repeat pill request.
When was your last cervical smear/PAP?  
Have you ever had an abnormal smear/PAP?    

Next of Kin
Who you would like us to contact in the event of an emergency

Confidentiality
The practice treats the information you provide as confidential. Further information about
how your data is used is available to view on our website.
The following systems use your data and you will need to either opt in or opt out of the data extractions.
These answers are mandatory.
Summary Care Record (SCR) - A national NHS system where a summary of your GP medical record (such as significant diagnoses,
allergies & medications) is available to be accessed by other healthcare providers across the country.  Use of this system is audited.
* Please express your agreement to this:  
  
Care.Data (please note: The Government has put this initiative on hold for the moment) - NHS England can instruct the
Health and Social Care Information Centre (HSCIC) to extract patient identifiable, medical information stored in your
GP record, to enable them to carry out national audits/identify trends and other analysis of this information.
HSHSCIC can then pass this information onto other organisations/third parties for use as they see appropriate.
* Please express your agreement to this:  
  

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