University Student Registration Form

University Student Form

It takes up to 10 working days to process your registration. To avoid delays, please provide all the information requested – otherwise our admin team will have to contact you for queries or missing information – together with all up-to-date contact details. Once your registration is complete, you will become a registered patient at Amwell Group Practice and will be able to access our full range of services that include completing a website eConsult for the doctor, booking an appointment with a member of our team and requesting your repeat medication. Please note: should you have an urgent health issue that really cannot wait and you believe needs to be dealt with urgently, please contact a member of our admin team who will be able to help if your registration is still being processed.

Personal Information

Preferred Title

Name

First Middle Last

Date of Birth

Place of Birth

What option best describes your gender?

Is your gender identity the same as the gender you were given at birth?

Are you intersex?

Which option best describes how you think of yourself ?

Ethnicity

Home Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Room Number

Phone Number

Email Address

Have you registered with the NHS before?

Are you from abroad?

If previously a resident in the UK, leaving date Optional

Date you first came to the UK?

Organ & Blood Donation

Are you ordinarily a resident of the UK?

Would you like to register as an organ donor? Optional

Are you or would you like to register as a blood donor? Optional

Non-UK European Health Insurance Card (EHIC), Provisional Replacement Certificate (PRC) Details:

Do you have a UK-EHIC or PRC? Optional

S1 form

The S1 form is a certificate of entitlement for state healthcare paid for by the UK government.

Do you have a S1 form?, If yes, please upload your file or give your S1 form to the practice's staff. Optional

Upload your S1 Form Optional

Max. file size: 50 MB.

PATIENT DECLARATION

Phone OptionalThis field is for validation purposes and should be left unchanged.