Ridgmount Practice Registration Form

UCL Ridgmount 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?

UCL UoL

Please indicate if you are:

Undergraduate Postgraduate Affiliate

Name of department or institution:

* Name of course:

* Start date of course:

* Approximate finish date of course:

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:

Mr Mrs Miss Ms

* Family/Surname:

* All first names:

Known as/Calling name:

Previous family/surname:

Marital status:

* Date of birth:

Patients aged 40 years and above will be sent an appointment
for a face to face New Patient Health Check with the nurse.

NHS No. (if known):

---------

Gender:

Male Female Other

* Town and country of birth:

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

Student Halls:

House/Room/Flat/Studio/Block no:

* Street Address:

Area:

* Town:

* Postcode:

* Mobile telephone number:

* If required, are you happy for us to contact you via SMS/text? Yes No

* E-mail Address:

* Confirm E-mail Address:

* If required, are you happy for us to contact you via email? Yes No

	* Name:
Next of kin details	* Phone no:
	* Relationship:

* If required in an emergency situation, do you give Ridgmount Practice the permission
to discuss your medical records with the above person? 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
* Previous Address in UK: (i.e. last address before going to Uni/College) * Town: * Postcode:
* Name of Doctor or Surgery when at that address:
* Address of Doctor or Surgery: * Postcode:

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

* Date when you arrived in UK:

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

* Confirmation:

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.