Cheltenham Road Surgery

Student Registration

If you are a student at The Oxstalls Campus of the Universtity of Gloucestershire and would like to register with the Cheltenham Road Surgery please complete the form below.

If you are not already registered with a medical practice in Gloucester please complete the form below. It is expected that, for ease of administration, students living in Gloucester will normally register with the Cheltenham Road Surgery.

PERSONAL DETAILS
the following fields are mandatory *
Title
Surname *
First name(s) *
Previous surname
Date of Birth *
Sex *
Please select Male Female
What is your height?*
What is your weight?*
Town and country of birth
Address with postcode (where you will be living whilst at university)
Telephone number *	Mobile number
NHS number (if known)
Please indicate your ethnic origin. This is not compulsory but may help with your healthcare.
Please Select White British White Irish White Other White & Black Caribbean White & Black African White & Asian Indian Pakistani Bangladeshi Chinese Other
Please let us know your first spoken language*
VACCINATIONS
If you have had the following vaccinations, please enter date(s)
MMR Date 1st	MMR Date 2nd
Meningitis Date
LIFESTYLE
Do you smoke?* No Yes
Have you ever smoked?* No Yes
We advise all smokers to stop. If you need help please make an appointment with a surgery nurse.
How many units of alcohol do you drink per week?* (1 unit of alcohol = half a pint of lager or 1 measure of spirits)
PREVIOUS DETAILS
For UK residents
Previous address in the UK *
Previous doctor or practice and town *
For new UK residents
First UK address where registered with a general practitioner *
Date first came to live in the UK
If previous resident, date of leaving the UK
Date of return to the UK
*
Click 'Submit' to send your details to the surgery