New Patient Registration – Coventry University Medical Centre

Custom – Cov Uni – New Patient Registration Form

Please read the Patient Privacy Notice HERE before registering.

Have you read our privacy policy above?

You will need to read the privacy policy before you can continue using this registration form.

1. Your Details


Your University Accommodation Address


Contact Details

Do you give us permission to communicate with you by text?
Do you give us permission to communicate with you by email?
Summary Care Records Consent preference
Summary Care Records (SCR) are an electronic record of important patient information,created from GP medical records. They can be seen and used by authorised staff in other areas of the health and care system involved in the patient’s direct care.

Previous Address

Previous Address *
Previous Address
Have you previously been registered with a GP/Doctor in the UK?
Name and Address of Previous GP/Doctor in the UK
Name and Address of Previous GP/Doctor in the UK

Are you a carer? (You provide care or support to a student)
Do you have any communication needs?
Please provide your preferred means of communication

Height and Weight


Vaccine Status

Have you had your first covid vaccination?
Have you had your second covid vaccination?
Have you had your Booster Covid vaccination?

Health Questions

Pease note: If you are taking any medication, you will need to see a Doctor before you request a repeat prescription.

Do you have any of the allergies listed below?

Penicillin Allergy
Nut Allergy
Egg Allergy
Latex Allergy
Allergy to Animal
Reaction to ibuprofen
Reaction to paracetamol
Hay fever
Reaction to Amoxicillin
Reaction to Ceporex


Smoking Status
Would you like help to stop smoking?

Details of Course

Emergency Contact Details

Relationship to you:

Armed Forces

Are you returning from the Armed Forces?
Address before enlisting
Address before enlisting
Post Code

UK Residency

Are you ordinarily a resident of the UK?
Please select one option

European Economic Area (EEA) Country

Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?
For a list of EEA countries visit:
Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC)

Please enter your EHIC or PRC details below

Do you have an S1 Form?