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NEW PATIENT APPLICATION

APPLICATION FOR GENERAL MEDICAL SERVICES WITH THE UNIVERSITY OF SUSSEX HEALTH CENTRE

Correct contact details are essential in case we need to contact you via Email, Phone or Letter, regarding your medical care.

Supplying this information gives consent for us to contact you where medically necessary.

Please ensure all information is filled in as accurately as possible - missing or inaccurate information could delay your registration.

* denotes required

Personal Information

Previous NHS Details

Last Doctor Details

Course Details

Nationality and Ethnicity

Medical details

Smoking

Fast Alcohol Screening Test (FAST)

Electronic Prescriptions (EPS)s

Summary Care Record (SCR)

Supplementary Questions (Optional)

 

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NHS Choices

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Patient UK

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