UCLRidgmountRidgmount Practice

Student Patient Registration


Please fill in your details and click Next when complete. * = compulsory  (page 1 of 3)

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

Which University are you at?   
Please indicate if you are:       
Study course at university
* Start date of course:  When does your course start?
* Approximate finish date of course:  When does your course finish?
Please note: If your course finishes in less than 6 months from now, please contact the practice first, before you
complete your application, to find out if you are eligible to register. Email gpp@nhs.net or call 020 7387 6306.
* Title:
Please enter all your first names in full
Please enter the name you are called
Patients aged 40 years and above will be sent an appointment
for a face to face New Patient Health Check with the nurse.
 If you don't know your NHS number it's very important that you fill in part 1 and 2 below
Fill in your new ADDRESS or select your Student Halls from the list below
Please don’t register until you know your exact and full address
  Select your halls of residence from this list
Enter your own telephone number. Preferably your mobile number
* If required, are you happy for us to contact you via SMS/text?   
* Your e-mail address
* Confirm your e-mail address
  * If required, are you happy for us to contact you via email?   
Next of kin details 
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
* If required in an emergency situation, do you give Ridgmount Practice the permission
to discuss your medical records with the above person?
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

(i.e. last address before going to Uni/College)


Part 2: Fill in if you come from abroad (international student)
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
By ticking this box I confirm that I have filled
in this form to the best of my knowledge
and signed it with my own unique mark.
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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