Student Patient Registration
for Brownlow Health @ Marybone

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

 What year are you due to finish studying at University?
* 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 Contact your old surgery to get your NHS number. Failure to do so will slow down your registration.
* Gender:  
Please fill in this section if you are going to stay in University Accommodation
  Address in Liverpool:
(university accommodation)
Select your university accommodation address in Liverpool from this lists Disregard if you are in other accommodations

Please fill in this section if you are not going to stay in University Accommodation
Your address in Liverpool if you are not in university accommodation. NOT your old home address
Enter your own telephone number. Preferably your mobile number
We find that SMS/text messaging and email 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 email to send confidential medical information.
* May we contact you by email?
* May we contact you by SMS/text?
   
 
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
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
If you have a study visa, when does it expire?
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...
A confirmation message will be sent to this address.
* Signature:
Please draw your unique signature in the box
   
Health Questionnaire
 cm  kg
Think about all the moderate Physical Activities that you do in a typical week:
Moderate activities refer to activities that take moderate physical effort and make you
breathe somewhat harder than normal. This may include brisk walking, gardening,
dancing, cycling, exercise and sport which last for at least 10 minutes.
* Days per week
* Minutes per day
  * Ethnic origin:  
       
  Need interpreter:     
       
 
Are you a carer?     Do you have a carer?  
Please tick if have, or have had, any of the following ILLNESSES:
 
 
Have you ever been a member of the ARMED FORCES including the T.A.?  
 
OVER 45: Have you had any broken bones since aged over 45?  
 
WOMEN OVER 25: Have you ever had a smear test?      
All women over 25 should have a routine smear test and our reception team will invite you to
make an appointment for this potentially lifesaving test. Please ask if you have any concerns.
 
* Do you SMOKE?
      When did you stop?
    

How often do you have a drink that contains ALCOHOL?
  A number of alcohol units per week 
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?
Do you have a Disability?     
Please provide your preferred means of communication:
        
* Please note not all information is currently readily available *
 
Organ Donation
If you are interested in becoming an organ donor, please click this link to go to the organ donor registration page.
NHS Records
There are strict laws and regulations to ensure that your health records are kept confidential and can only be accessed by health professionals directly involved in your care.  There is some sharing of information as detailed below.  You can opt out of any of these at any time if you wish.
NHS Summary Care Record (SCR) - this is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had.  Having this information stored in one place makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed.
    
 
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.
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