Student Patient Registration (page 1 of 2)

Please fill in your details and click Next 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 Students’ Health Service to do so.
Please do not use this form to update your address or other details.

7 numbers student ID
Department where you will study at university
Study course at university
  Year due to finish course
* Title:
Please enter all your first names in full
Please enter the name you are called
 
If you don't know your 10 digit NHS number it's very important that you fill in part 1 and 2 below
Gender:
    , please give details:
 
* Select your new Bristol address from the lists below
 if you are staying in Halls:
Halls  of residence: Select your halls from this list. Disregard if you are in other accommodation
Enter your room or flat number, if known
* or: Type in your Bristol address below if you are
not staying in Halls:
Your address if you are not in university accommodation. NOT your old home address
Enter your own telephone number. Preferably your mobile number
Your personal e-mail address. A confirmation will be sent to this address.
University e-mail address.
We find that SMS/text messaging and e-mail are often the most efficient methods of contacting patients about routine matters.
E.g. to remind you of an appointment. We will never use text or e-mail to send confidential medical information.
Tick this box if you don't want us to contact you by e-mail:
      Tick this box if you don't want us to contact you by SMS/text:
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





Part 2: Fill in if you come from abroad (international student)
You can't register before you arrive in the UK
(only if you have previously registered with a GP)




* 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 note: The information you are submitting will be passed to the Student Health Service over the Internet which is not 100% secure. If you are worried about this you can instead obtain a GMS1 from the Health Centre which can be filled in and delivered by hand or post.
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