University Health Service Registration

1Information > 2Health & Lifestyle > 3Alcohol > 4Medicines & Reactions > 5Consent > 6International students
Title *

Title Mr Miss Ms Mrs Other Other
First Name *
Middle Name (If Applicable)
Family (Surname) *
Date of Birth Date of Birth * / DD / MM YYYY
Gender *

Gender Male Female
Email Address
Emails

Where possible we prefer to communicate by email with patients as this is sent securely via NHS mail (although you should always ensure that your own personal email is kept secure) and in some cases is more secure than post to communal addresses. We will email you with invitations to make appointments at the University Health Service (if appropriate). You will only receive communications from the University Health Service relating to your health.
I consent for the University Health Service to use my email address number as described above *

I consent for the University Health Service to use my email address number as described above Yes No
Text Messaging

The University Health Service use a text messaging service to communicate with patients. We may use your mobile number to send you:

-Appointment Reminders. (You also cancel appointments) by text
-Health promotion
-Information regarding test results
-Keep you informed of changes in Practice Services/Opening Hours.
-Invite you to attend for flu vaccinations or medication and annual reviews.

Text messages are generated using a secure facility but they are transmitted over a public network and onto a personal telephone and as such may not be secure. We will not transmit any information which would enable an individual patient to be identified.

Please ensure you keep the Practice up to date with your mobile phone number.
I consent for the University Health Service to use my mobile phone number as described above *

I consent for the University Health Service to use my mobile phone number as described above Yes No
Are you a carer? (Carers are people who care for a family member, a friend or another person in need of assistance or support with daily living. They include those caring for the frail aged, people living with long-term medical conditions, people with a mental illness, people with a disability and those receiving palliative care.) *

Are you a carer? (Carers are people who care for a family member, a friend or another person in need of assistance or support with daily living. They include those caring for the frail aged, people living with long-term medical conditions, people with a mental illness, people with a disability and those receiving palliative care.) Yes No
If you answer yes, who do you care for? e.g. parent, child (with disabilities), friend etc *
Next Of Kin

(e.g. parents, husband, wife, someone related to you)
Name
Relationship to you:
Contact Number

University Health Service Registration

University Health Service Registration

Emails

Text Messaging

Next Of Kin