New Patient Registration – Child or Young Person

Patient's Details

Have you checked that you are within our practice boundary? *

Yes

No

Please view our practice boundary.

Details of the child or young person being registered;

Gender *

Male

Female

Other (please state:)Other (please state:)

Surname: *

Previous Surnames:

First Name(s) *

Has the patient been known by any other names?

Yes

No

If yes please give details:

NHS Number:

If known

Town and Country of birth: *

Home Address: *

Is the patient home schooled?

Yes

No

Postcode: *

Name of School/Nursery:

Home Phone Number:

Mobile Phone Number:

Nationality:

Does the patient speak English?

Yes

No

Main spoken language (if not English):

What is your ethnic group? *

Which one best describes your White background? *

British

Irish

Irish Traveller or Gypsy

Any other White background

Which one best describes your Mixed background? *

White and Black Caribbean

White and Black African

White and Asian

Any other mixed background

Which one best describes your Asian or Asian British background? *

Which one best describes your Black or Black British background? *

African

Caribbean

Any other Black background

Which best describes your other ethnic group background? *

Arab

Any other ethnic group

Previous Details

Previous Address in the UK:

Please include postcode.

Previous Doctor's Details:

If you are from abroad

Registering with the NHS for the first time in the UK

Date you came to live in the UK:

Please use date format DD/MM/YYYY

If you are returning from abroad

Previously been registered with the NHS in the UK

Date you left the UK:

Please use date format DD/MM/YYYY

Date you returned to the UK:

Please use date format DD/MM/YYYY

Details of Child's Main Carer

i.e. The person who has LEGAL parental responsibility for the patient (a definition of Parental Responsibility is available here)

Relation to the patient: *

Surname: *

First Name: *

Contact Details (if different from above): *

Current Address (if different from above): *

Please tell us your preferred method of contact: *

Text Message

Email

Telephone

Post

Do we have permission to send you text messages? *

Yes

No

Who else has Legal Parental Responsibility?

Relation to the patient:

Surname:

First Name:

Contact Details (if different to the patient):

Current Address (if different to the patient):

Families Receiving Additional Support

Does the patient have a social worker? *

Yes

No

Please give details:

Is the patient on the Child Protection/Child in Need Plan? *

Yes

No

Please give details:

Is the patient in a care/foster home? *

Yes

No

Please give details:

Medical History

Please state any significant medical history of the patient:

Please state any significant family medical history:

Does the patient have any disabilities or distinguishing features?

Yes

No

Please give further details:

Is the patient on any repeat medication?

Yes

No

Please give details:

Does the patient suffer from any allergies?

Yes

No

Please give details:

Are the patients Child Immunisations up to date?

Yes

No

Lifestyle

Is the patient a smoker?

Yes

No

Does the patient consume alcohol?

Yes

No

Your Summary Care Record and the Sharing of Information

It is important that those caring for you have access to your medical information so they can treat you safely and effectively. Many patients think that if they are seen at a Hospital, by the Ambulance Service or by a District Nurse they can see the notes written by your GP. In most cases this doesn’t happen! Sharing your record for your care can only happen when you tell your GP Surgery that it’s ok.
How do I make my record available to other staff involved in my health care?
Simple. You complete this form.

A - Summary Care Record with Additional Information
Anyone registered with a GP practice in England, will have a “Summary Care Record” unless you have chosen not to. It includes: Current medication/ Allergies and details of any previous bad reactions to medicines / Your name, address, date of birth and NHS number.

However, unless you have specifically asked for “Additional Information” to be included, health and care professionals who do not know your medical history may not have the following:
Significant medical history (past and present) / Reason for medication / Anticipatory care information (such as information about the management of long term conditions) / Communication preferences / End of life care information / Immunisations

B - Full Electronic Health Record
Your full electronic health record from your GP Surgery can also be made available to health and social care staff. They will only be able to see this if they are involved in your direct care, and they must still ask for your permission before they look at it. This will also allow your GP Surgery to see what’s recorded about you when you’re seen elsewhere. If there are certain parts of your record that you wish to keep private, your GP Surgery can help with this.

C - Receiving messages via text
You can receive communications from your GP Surgery by letter and phone, however you have to give consent to receive text messages from the GP Surgery to your mobile phone. This includes; appointment reminders, test results, messages relating to your specific health need (e.g. a flu vaccination reminder), general health information that could benefit you, information about emergencies (e.g. winter pressures). Your phone number will not be provided to third parties.

D - Receiving messages via email
You can receive communications from your GP Surgery by letter and phone, however you have to give consent to receive messages from the GP Surgery to your email address. This includes; appointment reminders, test results, messages relating to your specific health need (e.g. a flu vaccination reminder, diabetic management plans), requesting you contact the GP Surgery if they have tried to contact you by telephone, general health information that could benefit you, information about emergencies (e.g. winter pressures)
Your email address will not be provided to third parties.

Your Decision – You can agree to however many of these options:

A - Yes, I am happy for additional information to be included in my Summary Care Record, this means healthcare staff treating me can see a summary of my medical history in addition to my medication and allergies

B - Yes, I am happy for my full health record to be shared by my GP Surgery. This will be available to health and social care professionals, who are currently treating me, and have my permission to view it.

C - Yes, I am happy to receive messages from my GP Surgery via text. Messages I receive will only relate to those listed in box C above.

D - Yes, I am happy to receive messages from my GP Surgery via email. Messages I receive will only relate to those listed in box D above.

E - No, I am not happy with any of the above options.

Consent Policies

Consent Policy for leaving messages and/or texting on the patients contact numbers
Please complete this consent form which will be saved on your GP record. You can notify us in writing if you wish to retract this at any time.

*

I consent to my GP practice leaving messages on any contact telephone numbers supplied to the practice to identify themselves as my GP practice and to ask me to contact them if I am not available. These messages may be left on answer machines or with other people answering the phone.

I do not consent to my GP practice leaving messages on any contact telephone numbers supplied to the practice to identify themselves as my GP practice and to ask me to contact them if I am not available. These messages may be left on answer machines or with other people answering the phone.

Access to Medical Records Online
It is now a requirement that all newly registered patients have access to their medical records online. It is your choice if you wish to use this online access.
Once you are registered with the surgery you will receive two text messages one with your online username and the other with your online password.
To ensure you will receive these messages please give us an up to date mobile number and sign below to consent to us sending you appropriate SMS messages.

I am happy to receive SMS (Text) messages from Mill Road Surgery.

Signed: *

Date form completed: *

Consent to share information

Those with parental responsibility for children under the age of 13 yrs will automatically have the right to view their child’s medical record and share information with medical professionals.
At this practice we will share medical records for children up to the age of 16 yrs with those who have parental responsibility. Above the age of 16 yrs we will not release medical information even to those with parental responsibility unless express consent is given by the child.

However above the age of 13 yrs of age children can request not to share medical information even to those with parental responsibility, if they have the capacity (understanding of the consequences of their decision) should they wish, except in the instance of safeguarding information (if a child was at risk of abuse or exploitation).

Please speak with reception should you require more information.

*

I confirm that I have completed this form as accurately and honestly as possible and would like to apply to be registered at this practice.

Please bring the patient's birth certificate to the practice within 7 days to register, so that a copy can be taken.

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New Patient Registration – Child or Young Person

Patient's Details

Previous Details

If you are from abroad

If you are returning from abroad

Details of Child's Main Carer

Who else has Legal Parental Responsibility?

Families Receiving Additional Support

Medical History

Lifestyle

Your Summary Care Record and the Sharing of Information

Consent Policies

Consent to share information

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