New patient registration form

Thank you for applying to join the Campus View Medical Centre, please complete the online form below.

Once registered your Named Accountable GP will be Dr Gill.

Student ID number

Subject/Department of Course(Required)

Have you previously been registered with THIS Medical Centre?(Required)

Yes

Your contact details

By supplying your contact details, we will assume you are happy to receive information from the Practice such as appointment reminders via these methods. You can opt out at any time.

Your email address(Required)

Enter Email Confirm Email

NHS Number

Get help to find your NHS number online

Title(Required)

Mrs

Miss

Other

Forename (as appears on passport)(Required)

Surname (as appears on passport)(Required)

Date of Birth(Required)

Day

Month

Year

Gender(Required)

Male

Female

Unspecified

Your Town and Country of birth(Required)

University Halls or Loughborough Address and Postcode:(Required)

Home Telephone Number(Required)

Is this your preferred contact number?(Required)

Yes

UK Mobile Telephone Number

Please enter a UK mobile number for example +44 (09999) 999999

Is this your preferred contact number?(Required)

Yes

Previous GP

Please help us trace your previous medical records by providing us with the following information

Your full previous address in the UK

Previous GP name and address whilst at that address

If you are from abroad

If you are from abroad, please give the date you came to live in the UK

Day

Month

Year

If previously resident in the UK, please give the date of leaving

Day

Month

Year

Please give your FIRST UK address where you registered with a GP

Please tick if you would like to register for online access (i.e. book appts, order repeat meds, etc.)

Please tick for information on how to join our Patient Participation Group

Signature

Please enter your full name below(Required)

Today's date(Required)

Day

Month

Year

Medical information

Do you currently suffer from a significant medical condition(Required)

Yes

If you currently suffer from a significant medical which may require regular monitoring and/or treatment, please notify the Medical Centre as soon as possible to ensure continuity of care. Please bring with you to your first Doctor’s appointment your current medication list and/or a patient summary from your previous GP. This will prevent any delays in your treatment. Please note we cannot register patients on anticoagulants such as warfarin but you can register elsewhere in Loughborough.

Patients currently under the care of a Consultant

If you are being treated for a current condition by your consultant at a hospital whether via NHS or privately, please ensure you have your clinic letters sent to us before your first visit to see the GP. If you are being prescribed controlled medication via your consultant that requires monitoring, the practice will require a copy of the shared care agreement form that is usually sent to GP’s from your consultant. This should also be sent to us prior to your first visit so that we can continue to prescribe your medication here. Without this, we will be unable to prescribe certain medications for you and it may cause delays in treatment and continuity of care.

Are you allergic to any medicines?(Required)

Yes

If yes, please specify

Do you have any other allergies i.e. nuts, gluten, peanuts, certain foods, etc.?(Required)

Yes

If yes, please specify

Meningitis ACWY Immunisation

NHS England strongly recommends anyone who is starting University aged 18-24yrs have an ACWY booster if you haven’t already done so.

Booster(Required)

Yes, I would like a booster

No, I would not like a booster

I have already had an ACWY booster

If you would like a booster, we will contact you when our clinics are on

Please give a date when you had your booster(Required)

Day

Month

Year

Your immunisation history

Please ensure you have this to hand when you register at the Medical Centre. This will avoid delays in you receiving any treatment for travel/routine immunisations.

Smoking status

What is your smoking status?(Required)

Never smoked

Ex-smoker

Current smoker

Carers information

Are you the primary carer for someone with a disability, physical or mental need?(Required)

Yes

If yes, please specify who you care for

The Accessible Information Standard

Do you have any specific communication needs i.e braille, large print, etc?(Required)

Yes

If yes, please specify

Do you have any disabilities, illnesses or accessibility needs?(Required)

Yes

If yes, how can we support your needs?

Are you an Adult with social care involvement?(Required)

Yes

If yes, please state the reason why

About you

Your Ethnicity(Required)

White (British)

White (European)

White (Mixed)

White (Other)

Black African

Black Caribbean

Black (Mixed)

Black Other

Asian (Chinese)

Asian (Indian)

Asian (Pakistani)

Asian (Iranian)

Asian Other

Middle East (Arab)

Middle East (Israeli)

Middle East (Iranian)

Middle East Other

Mixed (White & Asian)

Mixed (White & African)

Mixed (White & Caribbean)

Mixed Other

Alcohol consumption - How many units of alcohol do you consume in a week?

Approximately - 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits. 1 unit of alcohol = 10cc of alcohol. So, a small glass (125cc) of 12% wine is 12.5 * 0.12 = 1.5 units. Find out more about alcohol units on the NHS website

How often do you have a drink containing alcohol?(Required)

Never

Monthly or less

2 to 4 times / month

2 to 3 times / week

4+ times / week

How many units of alcohol do you drink on a typical day when you are drinking?(Required)

None

1 - 2

3 - 4

5 - 6

7 - 9

10+

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?(Required)

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Part one score

A score of less than 5 indicates lower risk drinking

Alcohol consumption – Part Two

Scores of 5 or more in Part 1 requires the following 7 questions to be completed

How often during the last year have you found that you were not able to stop drinking once you had started?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

How often during the last year have you failed to do what was normally expected from you because of your drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

How often during the last year have you had a feeling of guilt or remorse after drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

How often during the last year have you been unable to remember what happened the night before because you had been drinking?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

Have you or somebody else been injured as a result of your drinking?
No
Yes, but not in the last year
Yes, during the last year

Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?
No
Yes, but not in the last year
Yes, during the last year

Score - part 2
0 – 7 Lower risk, 8 – 15 Increasing risk, 16 – 19 Higher risk, 20+ Possible dependence.

Total Score for alcohol questionnaire(Required)

If registering a Child please complete the following questions

If you are applying on behalf of a child who is in foster care/residential care/Kinship care/ or who is not your child.

Who has the parental or legal responsibility for the child?
You as the legal parent/guardian/adoptive parent
Other

Please supply your name, contact number and let us know the evidence of parental responsibility (birth certificate/social care information)

If you are the parent/guardian/foster carer /kinship carer but cannot consent please detail below who can
Please give a name, contact number and the relationship to the child

Looked after Children

If a child, are they looked after?
Yes
No

If yes, under what arrangements
Section 20-Voluntary Care
Placed for adoption
Subject to an Interim Care Order
Unaccompanied Asylum Seeker
Subject to a Full Care Order

Data Sharing

NHS patient information sharing - Summary Care Record

Your SCR is an electronic summary of key medical information taken from your GP medical record that can be accessed if you need urgent care away from your GP surgery to help give you better and quicker care. For more info visit: NHS Health Records

NHS Summary Care Record(Required)
You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care.
Yes, Express consent for medication, allergies and adverse reactions only
Yes, Express consent for medication, allergies, adverse reactions AND additional information
No, I do NOT want a Summary Care Record

Enhanced Data Sharing Module (EDSM)

We use a clinical computer system called SystmOne to record your medical information. With your consent, you can allow your full GP record to be shared with other healthcare services that are providing care for you and who also use SystmOne. These other services will always ask consent to view your record. For more info, please visit our website. Please note you will be opted IN to the Enhanced Data Sharing Module unless you notify the practice that you wish to opt out. You will be opted out automatically if you ticked no to having a summary care record.

Risk Stratification Preferences

Risk stratification is the process of identifying the relative risk of patients in a population by analysing their medical history. It's a key enabler for improving the quality of care delivered by the NHS. CVMC is taking part in the Risk Stratification programme and will be uploading patient identifiable data for analysis. Patient identifiable information will only be viewable at GP practice level. Any NHS organisation external to the practice using risk stratification will only see anonymised data. You have already been opted in to this service however, you can:
Tick this box if you wish to opt-out of the Risk Stratification programme

Accessing information

Visit our website for more information on how to access care and services at the medical centre, what to do when we are closed and other health/practice related information.

Not for urgent medical help(Required)
Yes, I understand this form is NOT for urgent medical help

Consent(Required)
By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.
I agree to the privacy policy.

Thank you for registering with the Campus View Medical Centre

You should be added to our practice register within 10 working days. Once you have registered, you will receive a text message confirming your registration. Any relevant information based on your completed registration form will also be sent to you after this. If you do not receive a text within 4 weeks of handing in your form, please contact the Medical Centre.

Comments
This field is for validation purposes and should be left unchanged.

Call us: 01509 277577

Your contact details

Previous GP

If you are from abroad

Signature

Medical information

Patients currently under the care of a Consultant

Meningitis ACWY Immunisation

Your immunisation history

Smoking status

Carers information

The Accessible Information Standard

About you

Alcohol consumption - How many units of alcohol do you consume in a week?

Alcohol consumption – Part Two

If registering a Child please complete the following questions

Looked after Children

Data Sharing

NHS patient information sharing - Summary Care Record

Enhanced Data Sharing Module (EDSM)

Risk Stratification Preferences

Accessing information

Thank you for registering with the Campus View Medical Centre

Helpful links

Further Info