New Student Registration Step 1 of 5 20% Please complete the below New Patient Registration Form. Please do not click the submit button more than once. It may take a few seconds to submit the information. Once you have completed the form you will become a registered patient and will be able to access our full range of services including the ability to book appointments & request medication.Patient's DetailsTitle Mr Mrs Miss Ms Mx Full Name First Surname Previous Surnames Date of Birth Day Month Year NHS Number Optional Immigration Health Surcharge (IHS) Number Optional Sex Male Optional Female Optional Country and Town of Birth Are you currently living in halls of residence? Yes No Current Address Street Address Address Line 2 City Post Code Halls of Residence AddressChapter Kings Cross, 200 Pentonville Rd, Kings Cross, London N1 9JUrbanest, Canal Reach, Kings Cross, London N1C 4BDRoom Number Email Address Please ensure that your email address is correct.Do you give us permission to communicate with you by email? Yes No Mobile Number OptionalDo you give us permission to communicate with you by text? Yes Optional No Optional Have you registered with the NHS (National Health Service) before? Yes No Are you from abroad? Yes No If you are from abroad please state the date you first came to live in the UK Day Month Year Please help us trace your previous medical records by providing the following informationAddress Street Address Optional Address Line 2 Optional City Optional Postcode Optional Were you registered with a GP while living at the above address? Yes No Name of Doctor's Surgery while living at the above address Address of Doctor's Surgery while living at the above address Street Address Address Line 2 City Postcode If you need your doctor to dispense medicines and appliancesNot all doctors are authorised to dispence medicines.Proximity to chemist I live more than 1 mile in a straight line from the nearest chemist Optional I would have serious difficulty in getting them from a chemist Optional NHS Organ Donor registrationFor more information on organ donation please visit: www.organdonation.nhs.ukNHS Blood Donor registrationFor more information, please ask for the leaflet on joining the NHS Blood Donor Register.I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood. Tick here if you would be prepared to donate blood Optional Tick here if you have given blood in the last 3 years Optional About Your HealthHeight Optional Weight Optional Please list below any medical conditions you have such as, high blood pressure, heart disease, heart attacks, cancer, asthma, stroke, diabetes, epilepsy, glaucoma, mental health issues, TB, thalassaemia or sickle cell disease, or any other major medical problems OptionalPlease include the condition and date of diagnosis.Have you ever been admitted to hospital for an illness/operation at any time in your life, including abroad? Optional(e.g. having your tonsils out, appendix removed, heart attack etc.) Please include the reason and date of admission.Are you taking any regular medications? Yes No (e.g. tablets, inhalers, pills, ‘the pill’, patches, etc.)Please list your medicationDo you have any allergies? Yes Optional No Optional Please list your allergiesAbout your family's healthHave any of your family (brother/sister, parents, grandparents, aunt/uncle etc.) had any of the following? Cancer Optional Heart Disease (under the age of 60) Optional Heart Disease (Over the age of 60) Optional High Cholesterol Optional Stroke Optional Diabetes Optional Asthma Optional No Optional Please specify which family members suffer/suffered from which condition About Your LifestyleSmoking StatusDo you smoke? Yes No I used to How many times did/do you smoke per day? How long did/have you smoke(d) for? What year did you stop? Drinking This is one unit of alcohol: And each one of these, is more than one unit: Do you drink alcohol? Yes Optional No Optional In a typical week how many units of alcohol do you drink based on the above? How often do you have a drink containing alcohol? Less than monthly 2-4 times a month 2-3 times a week 4 or more times a week How many units of alcohol do you drink on a typical day when you are drinking? 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? Never Less than monthly Monthly Weekly Daily or almost daily HiddenAlcohol Score OptionalAlcohol Additional QuestionsHow 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 EthnicityPlease state your ethnicityPlease Select…White EnglishWhite Northern IrishWhite IrishWhite ScottishWhite WelshWhite CypriotWhite GreekWhite Greek CypriotWhite TurkishWhite Turkish CypriotWhite ItalianWhite PolishWhite KosovanWhite AlbanianWhite BosnianWhite KurdishWhite and Black CaribbeanWhite and Black AfricaWhite and AsianBangladeshi/British BangladeshiBritish AsianIndian/British IndianBlack BritishBlack AfricanBlack NigerianBlack SomaliChinese – MandarinChinese – CantoneseJewishIranianArabLatin AmericanNorth AfricanOtherDo not wish to disclosePlease specify Do you speak English? Well Poorly No Do you need an interpreter? Yes No What is your first language? What is your second language? (if applicable) Optional Information SharingYour CareMyWay Integrated Digital Record will bring all your health and social care information together in one up-to-date record. This means that when you visit different health and social care services, you will not have to repeat all aspects of your history each time.Are you happy to participate in the CareMyWay initiative? Yes No The Practice uploads information to the Summary Care Record which is a system that allows other urgent care services such as Out of Hours and A&E to see important elements of your health record (e.g. medication, allergies & adverse reactions).Are you happy for your information to be shared in this way? Yes No Signature (Your Full Name)Confirmation of correct information By typing my full name in this signature box, I confirm that the information I have recorded in this registration form is correct to the best of my knowledge.