Registration form (under 16)

TitleMasterMiss

First Name *

Middle Name

Last Name *

Date of Birth *

NHS Number (if known)

Previous Surname

What sex were you assigned at birth?MaleFemale

Town and country of birth *

Current Address

Street Address *

Apartment, suite, etc

City *

State/Province

ZIP / Postal Code *

Country

Phone Number *

Previous addresses

Please help us trace your previous medical records by providing the following information. These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and charity services.

Your previous address in the UKN/A

Name of previous GP Practice while at that address

Address of previous GP practice

Are you from abroad? *YesNo

Were you previously living in the UK> *YesNo

Please provide your first UK address where registered with a GP *

Date you first came to live in the UK

If previously resident in UK, date of leaving: *

If your GP needs to dispense medicines or appliances, do you consent to your prescription being sent electronically? *YesNo

Please can you state your preferred pharmacy: *

If you are housebound and would be unable to visit your localy pharmacy, please state here: *Yes, I am houseboundN/A

Signature *Signature of PatientSignature on behalf of patient

Sign here *

Date *

What is your ethnic group *Please choose the boxes that best descripes your ethnic group or background from the options below:

White

Other white background

Mixed background

Other Mixed background

Asian

Other Asian background

Black

Any Other Black background

Other Backgrounds

Any Other background

Patient registered forNHS England use only

SUPPLEMENTARY QUESTIONS

These questions and the patient declaration are optional and your answers will not affect your entitlement to register or receive services from your GP.

PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

Anybody in England can register with a GP practice and receive free medical care from that practice. However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nati onals of countries outside the European Economic Area must also have the status of ‘indefnite leave to remain’ in the UK. Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges. More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leafet, available from your 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 confrm any details you have provided.

Are you ordinarily resident in the UK? *YesNo

Please tick one of the following boxes:I understand that I may need to pay for NHS treatment outside of the GP practice.I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge (“the Surcharge”), when accompanied by a valid visa. I can provide documents to support this when requestedI do not know my chargeable status

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.

A parent/guardian should complete the form on behalf of a child under 16.

Signed *

Date

Print name

On behalf of

Relationship to patient

Complete this section if you live in an EU country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS .

Do you have a non-UK EHIC or PRC?YesIf yes, please enter details from your EHIC or PRC below. f you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certifcate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

Country Code

Name

Given Names

Date of Birth

Personal Identifcation Number

Identifcation number of the institution

Identifcation number of the card

Expiry Date

PRC validity period (a) From:

(b) To:

Please tick if you have an S1 (e.g. you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state). Please give your S1 form to the practice staff.

How will your EHIC/PRC/S1 data be used?

By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process. Your EHIC, PRC or S1 information will be shared with Business Service Authority for the purpose of recovering your NHS costs from your home country.

Practice Questionnaire

Whilst we are waiting for your child’s full medical records from their last doctor, it would help us if you could take the time to complete this questionnaire so that your child’s care is transferred as seamlessly as possible. Please bring in your child’s red book so we can take a copy of their immunisation record

Please list other residents of your home who are registered with us:Name, DOB

Looking after a family member/carer

Is your child looking after someone?YesNoLet us know if your child is looking after someone who is ill, frail, disabled or has mental health and/or emotional support needs, or substance misuse problems

Is someone looking after your child?YesNoLet us know if a family member, friend or neighbour looks after your child due to ill health

Carer's name

Relationship to child:

Address of carer:

Carer's phone number

Your child religion

Your child's ethnic origin

What is your child's main spoken language?

Does your child need an interpreter?YesNo

Is your child housbound?YesNo

Comments:

Medical Background

Are there any serious diseases that affect your child's parents, brothers, or sisters? Tick all that apply and state family member:

Diabetes

Yes

Who

Asthma

Yes

Who

Thyroid disorder

Yes

Who

Stroke

Yes

Who

COPD

Yes

Who

Heart Attack under age of 60

Yes

Who

Cancer (specify type)

Yes

Type of cancer and who

High Blood pressure

Yes

Who

Any other important family illness (please state)

Yes

Please specify the illness and who

Please specify any allergies and sensitivities that your child has to medicines, food and dressings:

Please specify any mental disabilities your child has:

Does your child has any problems taking medicines?YesNo

If yes please give details, e.g. swallowing

What chronic medical condition has your child had? Please include date of diagnosis

What operations has your child had? Please include date of operation

What injuries has your child had? Please include date of injury

Please list any tablets, medicines or other treatments your child is currently taking / undertaking:

Which vaccination has your child had?

It is very important that you let us know the dates and types of vaccines that your child has had so that we have an accurate record. If your child has had vaccines abroad and you are unsure for what then please make an appointment with the practice nurse to discuss. Please bring a copy of any vaccines records with the registration form

Sharing your child's medical record

Medical Record Sharing allows your child’s complete GP medical record to be made available to authorised healthcare professionals involved in your care. You will always be asked your permission before anybody looks at your child’s shared medical record.

If you don't wish to share your child's GP record tick hereI don’t wish to share your child’s GP record tick here

Summary Care Records containe details of your child’s key health information – medications, allergies and adverse reactions. They are accessible to authorised healthcare staff in A and E Departments throughout England. You will always be asked your permission before anybody looks at your child’s Summary Care Records.

If you don't want your child to have a Summary Care Record tick hereI don’t want your child to have a Summary Care Record tick here

The Care.data Programme Collates information about your child and the care they receive. It links information from all the different places where your child receives care, such as their GP, hospital and community service, to help them provide a full picture of your child’s medical needs and the care they are receiving. This data is made available to NHS Commissioners so that they can design integrated service and is shared with third parties for research purposes.

Sharing data outside practiceI wish to OPT OUT from my child’s Personal Confidential Data Being shared outside their GP practiceI wish to OPT OUT from my child’s Personal Confidential Data being shared with third parties

Required Information

Parent Name/s *

Name of the person with legal parental responsibility

Name of school or nursery attended

ask text

Parent / Guardian permission given

Permission given for someone other than parents / guardian to accompany your child to an appointment

Name of the person

Relationship

Signature (to confirm permission)

By ticking this check box, I confirm that the information provided are accurate to best of my knowledge

Date