Ridgmount Practice

          Student Patient Registration (page 1 of 3)

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

Please indicate if you are:       
Study course at university
* Start date of course:  When does your course start?
* Approximate finish date of course:  When does your course finish?
Please note: If your course finishes in less than 6 months from now, please contact the practice first, before you
complete your application, to find out if you are eligible to register. Email gpp@nhs.net or call 020 7387 6306.
   
* Title:
Please enter all your first names in full
Please enter the name you are called
 
 If you don't know your NHS number it's very important that you fill in part 1 and 2 below
Gender:      
 
Please fill in your new ADDRESS or select your Student Halls from the list below
  Select your halls of residence from this list
Enter your house/room/flat/studio/block number
Enter your own telephone number. Preferably your mobile number
* E-mail Address: Your e-mail address
* Confirm E-mail Address: Confirm your e-mail address
If required, are you happy for us to contact you via SMS message or email?   
 
Next of kin details 
 
 
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
 
If required in an emergency situation, do you give Ridgmount Practice the permission
to discuss your medical records with the above person?
   
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 Uni/College)

*




Part 2: Fill in if you come from abroad (international student)
Have you lived or studied in the UK before?    
   
* 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 Practice over the Internet which is not 100% secure. If you are worried about this you can instead obtain a registration form from the Practice which can be filled in and delivered by hand or post.
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