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

Have you ever registered
with this practice before?
 
 Please go to the practice with a guardian to register in person if you are under 16.
* 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:     
Marital status:   
Please fill in your new ADDRESS at University or select your accommodation from the list
Select your accommodation from this list. Disregard if you are in other accommodations.
Enter your own telephone number. Preferably your mobile number
We will use your mobile telephone number to SMS (text) you to confirm we have registered you, and in future to send you automatic appointment reminder texts before any booked appointments, for occasional invitations to health screening events, and if applicable, to telephone you about important positive test results. We will NOT use any of your contact details for marketing etc. We will not disclose your contact details to any other organisation without your permission. Tick this box if you do NOT want us to use your mobile telephone number for these SMS messages:
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 university)







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?    
* Signature:
Please draw your unique signature in the box
   
Health Questionnaire
  * Ethnic origin:  
  Need interpreter:     
 
 
 
   
 
 
EMERGENCY CONTACT 
 
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
 
 cm  kg
 
* Do you SMOKE?     
     
* Amount you smoke per day:    
For help with stopping smoking, please visit www.smokefree.nhs.uk or text TXTHELP to 63818.
*
 
EXERCISE - In an average week how often do you take exercise which leaves you
mildly out of breath, and makes you perspire slightly?
 
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
Further information can be found in the Alcohol section of our website.
 
Summary Care Records (SCR)
The NHS in England has introduced the National Summary Care Record. The record will contain information about your health. This will ensure those caring for you have enough information to treat you safely. Records are kept securely on computers separate from the medical record Leeds Student Medical Practice will keep for you. Both records are created for you by default unless you choose to opt out.
For more information about NHS sharing you can talk to the Patient Advice and Liaison Service (PALS) on 0800 0525 270 or visit www.nhscarerecords.nhs.uk
You can choose not to have a Summary Care Record and you can change your mind at any time. If you do nothing we will assume that you are happy with these changes and create a Summary Care Record for you.
Children under 16 will automatically have a Summary Care Record created for them unless their parent or guardian chooses to opt them out. If you are the parent or guardian of a child under 16 and feel that they are old enough to understand, then you should make this information available to them.
 
Brunel Medical Centre has a Patient Participation Group where patients can give their views and
feedback on the services provided by the Medical Centre and suggest improvements.
 
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 registration page.
 
Please note: The information you are submitting will be passed to us over the Internet which is not 100% secure. If you are worried about this you can instead obtain a form from the practice which can be filled in and delivered by hand.
* = Compulsory.
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