Yiewsley Family Practice - New Child Registration

 

1. Title *

 

2.
Name *

*
*
 

3. Date of Birth *

   DD/MM/YYYY 
 
 

4. NHS Number (if known):

 

5. Gender *

 

6. Home Adrress *

*
*
*
 

7. Contact details *

*
*
 

8. Please help us trace your previous medical records by providing the following information.

Previous GP

 

Previous Address in the UK

 

9. If you are from abroad

 

10. What is your child's country and town of birth *

*
*
 

11. Family Details

 

12. Brothers, Sisters or other children’s details living in your home

Please give full names with dates of birth

 

13. Child Contacts

Please provide contact details (name, address and phone number) for the following.

 

14. Child Examinations

Please indicate which child examinations have been carried out

 

15. Immunisations

Please indicate which immunisations have been given to your child with dates

 

If there are any other vaccines your child has had that are not listed above please use the space below to provide the details of the jab, name and date they were given.

 

16. MEDICAL INFORMATION

Has your child had any serious illnesses or operations in the past, if so, please give details with dates

 

17. MEDICATION

Please list any medicines that your child is presently taking and the dosages:

 

18. Does your child have any allergies? *

 

19. Ethnic Status, Nationality & Language *

*
*
*
 

20. Please tell us your child's Ethnic Group by ticking a box *

 

21. ONLINE ACCESS to your child's medical records (please tick what you would like to do online)

 

22. ONLINE ACCESS AGREEMENT

I wish to access my child's medical record online and understand and agree with each statement (tick) *

 

23. SUMMARY CARE RECORD

A summary care record (SCR) is an electronic summary of key health information. It will hold limited essential information derived initially from your GP record. This will include medication, adverse reactions and allergies. If you wish to know more information regarding the system and the benefits please ask reception. Alternatively, visit the website: www.nhscarerecords.nhs.uk or call 0845 603 8510

Would you like to: *

 

24. SHARING YOUR MEDICAL INFORMATION WITH OTHER SERVICES

We may need to share your medical information with other organisations involved in the delivery of your care e.g. Podiatry or District Nursing. We will not share identifiable information with anyone that isn’t involved in your care unless legally required to.

Are you happy for us to Share Out your full medical records electronically with other services involved in your care and/or to view (share in) medical records held by other services? *

 

25. We would like to send you text messages to your registered mobile about your healthcare. This may include things like appointment reminders and test results. Is this OK? *

 

26. Would you like us to send you appropriate emails from the surgery? * *

 

27. PATIENT DECLARATION

Anybody in England can register with a GP practice and receive free medical care from that practice.

The NHS is the UK’s state health service which provides treatment for UK residents. Some services are free, other have to be paid for. A person who is regarded as ordinarily resident in the UK is eligible for free treatment by a GP. A person is ‘ordinarily resident’ for this purpose if lawfully living in the UK for a settled purpose as part of the regular order of his or her life for the time being. Anyone coming to live in this country would qualify as ordinarily resident. Overseas visitors to the UK are not regarded as ordinarily resident if they do not meet this description. If you are not a ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice.

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.

The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided. *

 

28. SIGNATURE ON BEHALF OF CHILD (Type your Name and Relationship) *

 

29. Date *

   DD/MM/YYYY