St Hugh’s Registration Form

Title

Surname: *

First Name(s): *

Previous Surname:

Birth Town: *

Birth Country: *

Telephone:

Date Of Birth (dd/mm/yyyy) *

NHS Number (if previously registered with NHS):

Sex *

Male

Female

Medical Records

Please help us to trace your previous medical records by providing the following information. If you are from abroad please move to the next section

Medical Records (abroad)

If you are from abroad please provide the following information:

Please note, if this is your first time in the UK you MUST provide date of entry or we are unable to register you.

Your first UK address where registered with a GP

Signature

If previously resident in UK, date of leaving

Date you first came to live in UK

If you are returning from the armed forces please provide the following information: Address before enlisting

Service/Personnel No.

Enlistment date

Signature

Signature Of Patient

Signature On Behalf Of Patient

Summary Care Record and Oxfordshire Care Summary – Your Choice

We recommend opting into Oxfordshire care summary records

Your choice for Summary Care Record *

I wish to share my information

I DO NOT wish to share my information

I wish to share my information WITH additional Information

I DO NOT wish to share my information WITH additional Information

Your Choice for Oxfordshire Care Summary *

I wish to share my information

I DO NOT wish to share my information

Important

It is important to complete this information as your new practice cannot make a decision for you. Without your direction, we cannot guarantee that your wishes will be met, even if you have previously made a similar choice in another practice. If the person signing below is not the patient, please also enter the signatory’s name and relationship to the patient, e.g. PARENT, GUARDIAN, ATTORNEY

Contact Details

We would like to be able to contact you by email and text on matters regarding your health or to text you reminders about your appointments. If you are happy for us to contact you in this manner please provide your email and mobile telephone number:

UK mobile (cell) number

Email address

Course subject

Address & telephone during vacations

Are you a post graduate student?

Yes

If yes please provide Oxford address, if unable please provide as soon as possible

Name and contact details of next of kin *

Name of doctor during vacation

Immunisation History

Please indicate which of the following diseases you have been vaccinated against. Where you tick 'yes' you will be asked for the date(s) you received the vaccination. If you have been vaccinated against a disease please indicate 'yes' even if you do not know the date(s) you received the vaccination.

Have you been vaccinated against measles/mumps/rubella (MMR)?

Yes

Please provide date(s) of vaccination

Have you been vaccinated against meningitis ACWY?

Yes

Please provide date(s) of vaccination

Have you been vaccinated against Covid-19? *

Yes No

Please provide dates of vaccinations.

Ethnicity & Language

Thank you

Thank you for completing this registration form. When your form is complete please press the submit button. Your registration form will be sent to the Practice. We will register shortly before you are due to start at your college. If you wish to, you can now use the internet to book appointments with your GP and request repeat prescriptions for any medications you take regularly. If you wish to use this service, please complete the details below and we will email your log in details to you.

Access to GP online services I wish to have access to the following online services (tick all that apply):

Booking appointments

Requesting repeat prescriptions

I am happy to have my access information emailed to me at the email address provided in my registration form. I understand this may not be secure and accept this risk. *

Yes No

Other info

You can also view your medical record online. This can help you manage your medical conditions. It also means you can access it from anywhere in the world should you require medical treatment on holiday. If you wish to sign up for medical record viewing, you will need to present at the practice to complete the appropriate form and to present proof of identification in the form of a passport or photo card driving license. It will be your responsibility to keep your login details and password safe and secure. If you know or suspect that your record has been accessed by someone that you have not agreed should see it, then you should change your password immediately.

Further Information