INTERNATIONAL STUDENT REGISTRATION FORM

International students seeking to use the services at Moor Park Paediatric Practice are required to complete this form.

This website makes use of several layers of security to ensure that your information is sent to us securely.

All mandatory fields are marked with an asterisk (*).

Name of Student*

Please enter your full name, including middle and last names
Date of Birth*
DD slash MM slash YYYY

Please enter your Date of Birth
Gender of Student*
Please select your gender
Prospective School in the UK*

Please enter the name of your Prospective School in the UK
Year at School*

Please enter your current year at School
Home Country Address*

Please enter your address in your Home Country
Home Country Phone Number*
Please enter your Home Country Phone Number, including your International Country Code e.g. +1
UK Phone Number*
Please enter your Phone Number here in the UK
Parent/Carer Information in Home Country
Name of Parent/Carer*

Please enter the full name of your Parent, Carer or Guardian
Relationship to Student*
Please specify the type of relationship
Address of Parent/Carer*

Please enter the address of your Parent/Carer
Phone Number of Parent/Carer*
Please enter the Phone Number of your Parent/Carer, including an International Country Code where applicable
Email Address of Parent/Carer*

Please enter the Email Address of your Parent/Carer
Parent/Carer Information in UK
Name of Parent/Carer in UK*

Please enter the full name of your Parent, Carer or Guardian in the UK
Relationship to Student*
Please specify the type of relationship
Address of Parent/Carer in UK*

Please enter the address of your Parent/Carer in the UK
Phone Number of Parent/Carer in UK*
Please enter the UK Phone Number of your Parent/Carer
Email Address of Parent/Carer in UK*

Please enter the Email Address of your Parent/Carer in the UK
Medical History
Name Family Physician in Home Country

Please include the Name of your Family Physician in your Home Country
Address of Family Physician

Please specify the Hospital address of your Family Physician in your Home Country
Phone Number of Family Physician
Please enter the contact Phone Number of your Family Physician in your Home Country, including the International Country Code where applicable
Email Address of Family Physician

Please enter the contact Email Address of your Family Physician in your Home Country
Name of General Practitioner in UK

Please enter the name of your General Practitioner here in the UK
Address of General Practitioner

Please enter the Address of your General Practitioner in the UK
Phone Number of General Practitioner in the UK
Please enter the contact Phone Number of your General Practitioner here in the UK
Email Address of General Practitioner in the UK

Please enter the contact Email Address of your General Practitioner in the UK
Have you had any known Medical Illnesses?*
Please specify if you've had any known Medical Illnesses
When did the Medical Illness start?
DD slash MM slash YYYY

If any, please specify when the Medical Illness started
When did the Medical Illness stop?
DD slash MM slash YYYY

If any, please specify when the Medical Illness stopped
Have you had any Surgical Operation(s)?*
Please specify if you've had any surgical operations
When did the Surgical Operation occur?
DD slash MM slash YYYY

Please specify when the Surgical operation occurred
Have you been admitted to a Hospital recently?*
Please specify if you have been admitted to any Hospital recently
Date of admission to Hospital
DD slash MM slash YYYY

Please specify when you were admitted to the Hospital
Date of discharge from Hospital
DD slash MM slash YYYY

Please specify the date you were discharged from the Hospital
Do you have any known Mental Health Illness?*
Please specify if you have any known Mental Health Illness
Date Mental Illness started
DD slash MM slash YYYY

Please specify when the Mental Illness started
Date Mental Illness stopped
DD slash MM slash YYYY

Please specify when the Mental Illness stopped
Allergy History*
Medical History*
Current Medications*
Immunization History*
Any known restrictions*
Please specify any known medical restrictions you may have
Do you have any other Medical concerns?
Please let us know what other Medical concerns you have, if any
Date of Form submission*
DD slash MM slash YYYY

Please specify the date this form is being submitted
Consent*
I hereby consent to the Terms and Conditions and Privacy Policy of Moor Park Paediatric Practice.
These terms and conditions outline the rules and regulations for the use of www.moorparkpaediatrics.com's Website.

By accessing this website we assume you accept these terms and conditions in full. Do not continue to use www.moorparkpaediatrics.com's website if you do not accept all of the terms and conditions stated on this page.

The following terminology applies to these Terms and Conditions, Privacy Statement and Disclaimer Notice and any or all Agreements: "Client", "You" and "Your" refers to you, the person accessing this website and accepting the Company's terms and conditions. "The Company", "Ourselves", "We", "Our" and "Us", refers to our Company. "Party", "Parties", or "Us", refers to both the Client and ourselves, or either the Client or ourselves. All terms refer to the offer, acceptance and consideration of payment necessary to undertake the process of our assistance to the Client in the most appropriate manner, whether by formal meetings of a fixed duration, or any other means, for the express purpose of meeting the Client's needs in respect of provision of the Company's stated services/products, in accordance with and subject to, prevailing law of United Kingdom. Any use of the above terminology or other words in the singular, plural, capitalisation and/or he/she or they, are taken as interchangeable and therefore as referring to same.

Cookies

We employ the use of cookies. By using www.moorparkpaediatrics.com's website you consent to the use of cookies in accordance with www.moorparkpaediatrics.com's privacy policy. Most of the modern day interactive web sites use cookies to enable us to retrieve user details for each visit. Cookies are used in some areas of our site to enable the functionality of this area and ease of use for those people visiting. Some of our affiliate / advertising partners may also use cookies

License

Unless otherwise stated, www.moorparkpaediatrics.com and/or it's licensors own the intellectual property rights for all material on www.moorparkpaediatrics.com. All intellectual property rights are reserved. You may view and/or print pages from https://moorparkpaediatrics.com for your own personal use subject to restrictions set in these terms and conditions.

You must not:

Republish material from https://moorparkpaediatrics.com

Sell, rent or sub-license material from https://moorparkpaediatrics.com

Reproduce, duplicate or copy material from https://moorparkpaediatrics.com

Redistribute content from www.moorparkpaediatrics.com (unless content is specifically made for redistribution)

Hyperlinking to our Content

The following organizations may link to our Web site without prior written approval:

Government agencies;
Search engines;
Online directory distributors when they list us in the directory may link to our Web site in the same manner as they hyperlink to the Web sites of other listed businesses; and Systemwide Accredited Businesses except soliciting non-profit organizations, charity shopping malls, and charity fundraising groups which may not hyperlink to our Web site.

These organizations may link to our home page, to publications or to other Web site information so long as the link: (a) is not in any way misleading; (b) does not falsely imply sponsorship, endorsement or approval of the linking party and its products or services; and (c) fits within the context of the linking party's site.

We may consider and approve in our sole discretion other link requests from the following types of organizations: commonly-known consumer and/or business information sources such as Chambers of Commerce, community sites; associations or other groups representing charities, including charity giving sites, online directory distributors; internet portals; accounting, law and consulting firms whose primary clients are businesses; and educational institutions and trade associations.

We will approve link requests from these organizations if we determine that: (a) the link would not reflect unfavourably on us or our accredited businesses (for example, trade associations or other organizations representing inherently suspect types of business, such as work-at-home opportunities, shall not be allowed to link); (b)the organization does not have an unsatisfactory record with us; (c) the benefit to us from the visibility associated with the hyperlink outweighs the absence of www.moorparkpaediatrics.com; and (d) where the link is in the context of general resource information or is otherwise consistent with editorial content in a newsletter or similar product furthering the mission of the organization.

These organizations may link to our home page, to publications or to other Web site information so long as the link: (a) is not in any way misleading; (b) does not falsely imply sponsorship, endorsement or approval of the linking party and it products or services; and (c) fits within the context of the linking party's site.

If you are among the organizations listed in paragraph 2 above and are interested in linking to our website, you must notify us by sending an e-mail to info@moorparkpaediatrics.com. Please include your name, your organization name, contact information (such as a phone number and/or e-mail

address) as well as the URL of your site, a list of any URLs from which you intend to link to our Web site, and a list of the URL(s) on our site to which you would like to link. Allow 2-3 weeks for a response.

Approved organizations may hyperlink to our Web site as follows:

By use of our corporate name; or
By use of the uniform resource locator (Web address) being linked to; or
By use of any other description of our Web site or material being linked to that makes sense within the context and format of content on the linking party's site.
No use of www.moorparkpaediatrics.com's logo or other artwork will be allowed for linking absent a trademark license agreement.

Iframes

Without prior approval and express written permission, you may not create frames around our Web pages or use other techniques that alter in any way the visual presentation or appearance of our Web site.

Reservation of Rights

We reserve the right at any time and in its sole discretion to request that you remove all links or any particular link to our Web site. You agree to immediately remove all links to our Web site upon such request. We also reserve the right to amend these terms and conditions and its linking policy at any time. By continuing to link to our Web site, you agree to be bound to and abide by these linking terms and conditions.

Removal of links from our website

If you find any link on our Web site or any linked web site objectionable for any reason, you may contact us about this. We will consider requests to remove links but will have no obligation to do so or to respond directly to you.

Whilst we endeavour to ensure that the information on this website is correct, we do not warrant its completeness or accuracy; nor do we commit to ensuring that the website remains available or that the material on the website is kept up to date.

Content Liability

We shall have no responsibility or liability for any content appearing on your Web site. You agree to indemnify and defend us against all claims arising out of or based upon your Website. No link(s) may appear on any page on your Web site or within any context containing content or materials that may be interpreted as libelous, obscene or criminal, or which infringes, otherwise violates, or advocates the infringement or other violation of, any third party rights.

Disclaimer

To the maximum extent permitted by applicable law, we exclude all representations, warranties and conditions relating to our website and the use of this website (including, without limitation, any warranties implied by law in respect of satisfactory quality, fitness for purpose and/or the use of reasonable care and skill). Nothing in this disclaimer will:

limit or exclude our or your liability for death or personal injury resulting from negligence;

limit or exclude our or your liability for fraud or fraudulent misrepresentation;

limit any of our or your liabilities in any way that is not permitted under applicable law; or

exclude any of our or your liabilities that may not be excluded under applicable law.

The limitations and exclusions of liability set out in this Section and elsewhere in this disclaimer:

(a) are subject to the preceding paragraph; and

(b) govern all liabilities arising under the disclaimer or in relation to the subject matter of this disclaimer, including liabilities arising in contract, in tort (including negligence) and for breach of statutory duty.

To the extent that the website and the information and services on the website are provided free of charge, we will not be liable for any loss or damage of any nature.

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INTERNATIONAL STUDENT REGISTRATION FORM

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Medical History

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