UEA Medical Services
Online Registration

CAN YOU REGISTER?

To be eligible to register at the UEA Medical Centre you must meet the following criteria:

1. You must have an affiliation with a university or research park

Accepted Affiliations with the University or Research Park: 1. A student or staff member at the University of East Anglia 2. An employee of the Norfolk & Norwich University Hospital or organisation in the Norwich Research Park 3. A contractor who is contracted to provide services for the university, research parks or hospital 4. A person co-habiting at the same address as someone in the above 3 criteria 5. Ex-patients wishing to re-register within 5 years of leaving the practice list

2. You must be entitled to NHS care

3. Your Norwich address is within our practice boundary

NEW STUDENTS – Please register no more than 7 days prior to arriving in Norwich
(in case you continue to need GP services at home until that time)

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 Medical Centre to do so.
If you are unsure of your registration status, you can contact the practice at umsuea@nhs.net who will be able to confirm this for you.  

Current patients: DO NOT use this form to update your address or other details. This can be done
via email: contact umsuea@nhs.net, including your full name and date of birth.

Have you ever registered with this practice before?	Yes   No
* Your affiliation with the university/research park:	Please select... UEA/College student University/College employee NNUH/Norwich Research Park employee Cohabiting with another patient Ex-patient INTO student Please note: proof may be required prior to fully accepting your registration
* Year of study:	Please select... Non-student UG 1st year UG 2nd year UG 3rd year UG Other PG 1st year PG other
* Course end date:	Please select... Not applicable 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033
School:	Please select... Art, Media and American Studies Arts and Humanities Biological Sciences Centre for Continuing Education Centre for Staff and Eductional Development Chemistry Computing Sciences Economics Education and Lifelong Learning Environmental Sciences Health Sciences History International Development Law Literature, Drama and Creative Writing Mathematics Medicine and Health Sciences Music Natural Sciences Norwich Business School Norwich Medical School Pharmacy Politics, Philosophy, Language and Communication Studies Psychology Science Social Work
* Title:	Mr   Mrs   Miss   Ms
* Surname (Family name):	Exactly as on your passport.
* First name(s):	Exactly as on your passport.
Previous surname(s):
* Date of birth:	Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916
NHS No. (if known):
* Gender:	Male   Female
* Town and country of birth:
Please fill in your new ADDRESS in Norwich or select your accommodation from the list
Accommodation:	Please select... Ash House Barton House Beech House Britten House Browne House Colman House Constable Terrace Courtyard A Courtyard B Crome Court Crown Place Elm House Hawthorn House Hickling House INTO UEA Kett House Larch House Nelson Court Norfolk Terrace Oak House Orwell Close Pablo Fanque House Paston House Pine House Suffolk Terrace Victory House Willow House Wolfson Close Yew House
Room/Flat:
House/Hall Name:
* Street Address:
* Town:
* County:
* Postcode:
UK Mobile telephone number:
* I confirm that this is my personal mobile 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:	from UK International
Part 2: Fill in if you come from the UK Previous address in UK before going to University: House Number: House Name: * Road: * Town: * Postcode: * Approximate date of first living at this address: Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 * 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: Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 How many months will you stay in the UK? * Have you lived or studied in the UK before? Yes    No Your UK address if registered with a GP: (only if you have previously registered with a GP) Block/Floor/Flat/Room/Number: House name/number: *Street name: * Town: * Postcode: Approximate Date of first living at this address: Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 If a previous resident in UK, date of leaving: Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Supplementary Questions: Anybody in England can register with a GP practice and receive free medical care from that practice. However, if you are not 'ordinarily resident' in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside of the European Economic Area must also have the status of 'Indefinite leave to remain' in the UK. Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges. More information on ordinary residence, exemption and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice. You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment regardless of advance payment. The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purpose of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided. 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 Immigration 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 Please enter details from your EHIC or PRC below: Country code: 3 Family Name: 4 Given names: 5 Date of Birth: (dd/mm/yyyy) 6 Personal Identification Number: 7 Identification Number of the Institution: 8 Identification number of the card: 9 Epiry Date: (dd/mm/yyyy) PRC validity period From: (dd/mm/yyyy) PRC validity period To: (dd/mm/yyyy) 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... How will your EHIC/PRC/S1 date be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purpose of cost recovery. Your clinical data will not be shared in the cost recovery process. Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.
* Email address:
* Confirm Email address:
* I confirm that this is my personal email address:
* Signature:	Clear
Communication Consent: May we contact you via text message or email? You can receive communications from us by email and phone, however you must express consent for this. (This includes appointment reminders, test results, messages relating to your specific health needs such as a flu vaccination reminder, general health information that could benefit you, information about emergencies etc).  Your phone number/email address will not be provided to third parties.
* SMS/text consent: Yes   No   * Email consent: Yes   No
Health Questionnaire
Nationality:     * Ethnic origin: Please select... British Irish Irish Traveller Traveller Gypsy/Romany Polish Any other White (please specify) White and Black Caribbean White and Black African White and Asian Any other Mixed (please specify) Indian Pakistani Bangladeshi Any other Asian (please specify) Caribbean African Somali Nigerian Any other Black (please specify) Chinese Filipino Any other ethnic group (please specify) Prefer not to say Other ethnicity: * Main language: Please select... Albanian Arabic Bengali Chinese English French German Greek Gujarati Hindi Italian Japanese Persian Polish Portuguese Punjabi Russian Serbo-Croatian Somali Spanish Turkish Urdu Vietnamese Other Other language: Need interpreter: Yes   No     * Have you lived in another country for 6+ months in the last year? Yes   No If yes, which country:
ROUTINE IMMUNISATIONS - essential information required You are strongly advised by the UEA, INTO & UEA Medical Centre to ensure you are fully immunised to UK Department of Health standards. 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: Yes, date: Yes, but unsure of date No * 1st MMR (measles, mumps, rubella) vaccine: Yes, date: Yes, but unsure of date No * 2nd MMR (measles, mumps, rubella) vaccine: Yes, date: Yes, but unsure of date No
Have you been diagnosed with any of the following CONDITIONS?
Diabetes: Eating disorder: Pre-Diabetes: Mental illness (on treatment): Epilepsy: Chronic Kidney Disease (CKD): Hypertension: Heart Disease: Asthma: Cancer (current): Stroke: On treatment for Gender transitioning: Repeat medication needing very regular blood tests: Rheumatoid arthritis: I have used an inhaler within the last 12 months: I use an inhaler 3 or more times per week:
Do you have any other SIGNIFICANT CONDITIONS / MEDICAL HISTORY?Yes   No  * Please state any conditions or medical history:
Do you have any DISABILITY/COMMUNICATION needs?Yes   No  * Please state any disability or communication needs:
Do you suffer from any ALLERGIES?Yes   No  * Please state any allergies you have:
Do you take any prescribed MEDICATION at present?Yes   No  (including the pill and depo-injections) * Please list any prescribed medicines you use: 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
* Are you a CARER?Yes   No  (Do you care for someone with specific needs?)
* Who do you care for?
Height: cm Weight: kg Only enter if measurement taken in the last 6 months. Your Body Mass Index (BMI) is:
* Do you SMOKE? Yes   Never   Used to smoke (not now)
* Amount you smoke per day:   Please select... Less than 1 per day 1 to 9 per day 10 to 19 per day 20 to 39 per day 40 or more per day For help with stopping smoking, please visit http://www.smokefreenorfolk.nhs.uk/ or call 0800 0854 113. Alternatively, Boots on campus and most other pharmacies run smoking cessation clinics. * Tick here to confirm that you have read the above:
* 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 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?Yes   No Do you require contraception?Yes   No   If you require the contraceptive pill, you will need to see a doctor or specialist sexual health nurse at the medical centre in the first instance to get this set up and issued.  Thereafter you will need to see a nurse for each contraceptive pill repeat.  (Those on Dianette will need to see a doctor) When was your last cervical smear/PAP? Not applicable   Date: Have you ever had an abnormal smear/PAP? Not applicable   No   Yes, date: Number of pregnancies:
Next of Kin
Who you would like us to contact in the event of an emergency Name: Contact Number(s):
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. Please note that if you have supplied us with your email address we may use this for medical correspondence. This is not encrypted. If you have any concerns regarding this, you will not be able to register with us online as it needs an email address. You have to come into the medical centre to register.
Our Data Protection Officer: www.kafico.co.uk
Your Information and Privacy Choose if data from your health records is shared for research and planning.  For more information visit https://www.nhs.uk/your-nhs-data-matters/
* Summary Care Record (SCR) Your Summary Care Record is a short summary of your GP medical records. It tells other health and care staff who care for you about the medicines you take and your allergies. To help the NHS to respond to the coronavirus (COVID-19) pandemic, additional Information will be included in Summary Care Records for patients by default, unless you have previously told the NHS that you did not want this information to be shared. Further information is available at this website
YES – I would like a Summary Care Record:   Express consent for medication, allergies and adverse reactions only or;   Express consent for medication, allergies, adverse reactions and additional information NO – I would NOT like a Summary Care Record   Express dissent for Summary Care Record (opt out)
Automatic Data Extractions The UK Government wishes to use your data for health and research purposes. Your anonymised data will be automatically extracted unless you choose to opt out. Please tick the following box if you wish to opt out from sharing your medical record with private, third party organisations. If you tick opt out, we will updated your data extraction wishes.  Opt out
* UEA Student Records We only access this system if we need to verify details. I opt IN   I opt OUT
*  I have read this section on confidentiality and expressed my choices:
Online access to medical records
The practice has recently changed how you can access your medical records online. Please see here for further information. Please note, if you wish to apply for this access, this must be done once your registration has been completed by the practice.
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.