Student Patient Registration

 

Only accepted students and ther dependants accompanying them to University
can use this form, and all names are cross-checked.

Please fill in your details and click "Next page" when complete (page 1 of 2). * = 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 to do so.
Please do not use this form to update your address or other details.

For example: BA, MSc, DPhil, MPhil, MSt, BM, BCL, BPhil, PGCE etc (e.g. BA, MSc, DPhil etc)
Study course at university
* Title:
Your surname as it appears on your passport
Please enter all your first names in full
 
  Please enter your 10 digit NHS number. It can be obtained from your previous surgery.   The N
 
Gender:
lease give details:  
 Where were you born?
The default address below is your College address. Please replace it with your address if you are not staying in your College.
If you do not have an Oxford address yet, please use your College address and inform the practice once your new address is known.
  (college / hall / house name) Your new address in Oxford. NOT your old home address.
Planned DATE of arrival in Oxford accommodation: Date when you plan to arrive at your Oxford address.
Enter your own telephone number. Preferably your mobile number
Your personal e-mail address. A confirmation will be sent to this address.
   
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)
Enter today's date if you haven't arrived yet.
Have you lived or studied in the UK before?    
 
   
(full name and phone no.) Name and phone number of the person to contact in an emergency
Your relationship with the Emergency Contact
 
* 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 Health Centre 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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