New Patient Registration Form

Nottingham Trent University Student Health Centre (Clifton campus) Online Registration

New Patient Registration Form

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 by the Medical Centre to do so. Please do not use this form to update your address or other details.

Have you ever registered with this practice before?
Arrival Date at University
Date of Birth


May we contact you using Email?
May we contact you using SMS Text?

Emergency Contact

How do you know this person?
Please select if you are from the UK or abroad

Health Questionnaire

Need interpreter
Are you a carer?
Do you have a carer?
Please tick if you have, or have had, any of the following ILLNESSES or tick None:
Do you Smoke?
How often do you have a drink that contains ALCOHOL?
How many standard alcoholic drinks do you have on a typical day when you are drinking?
How often do you have 6 or more standard drinks on one occasion?
Do you have a Disability or Special Communication Needs?

Women over 25

Have you ever had a smear test?
If you are over 25 and have not yet had a smear please make an appointment with the Practice Nurse.
Have you had HPV Vaccination?
NHS Records
There are strict laws and regulations to ensure that your health records are kept confidential and can only be accessed by health professionals directly involved in your care. There is some sharing of information as detailed below. You can opt out of any of these at any time if you wish. NHS Summary Care Record (SCR) – this is an electronic record which contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had. Having this information stored in one place makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed.