WIP: New Patient Registration - Under 18 Form

 
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All questions marked with a * are mandatory

Personal details of under 18
Gender at birth: *
 

Help Us To Help You 

Providing a NHS Number means that we can find a patient record more accurately, saving time and resources. 

How to find your NHS Number 

Does the child/family have any contact with a social worker?: *
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Person with Parental Responsibility

Other with Parental Responsibility or Next of Kin, if different from above

Communication Consent

Are you happy for us to leave you a voicemail message?: *
Are you happy for us to contact you by text message?: *
Are you happy for us to contact you by email?: *
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Present Illness/ Operations / Impairment
Do you have any of the following conditions:
Please tell us the date of when your condition started or was diagnosed
Please include dates.
Please include dates.
Please include dates.
How do you describe your sight?:
How do you describe your hearing?:
e.g. Sign Language
I give consent for the practice to share the above communication needs with other NHS providers. : *
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Immunisation History

Please bring your child's Red Book with you.

Has your child had the 5th dose of DTP / Polio vaccine: *
Provided for over 14’s
Has your child had Meningitis ACWY vaccine : *
Provided for over 14’s
Has your child had the HPV vaccine: *
Girls aged 14 and under 18’s
Please include dates.
Allergies
Do you have any allergies?: *
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Medication
Is your child on any repeat medication?: *
Please include the name of the medicatons, dosages, and how many times per day it is taken.
Have you got 4 weeks worth of their current medication?: *
Please contact your current provider to request 4 weeks worth of your medication before registering with the practice: *
You cannot continue with this form.
Do you have a nominated pharmacy for electronic prescribing?:
Nominate a pharmacy means we can send any prescriptions directly to the pharmacy without you needing to come to the practice
include the full address and post code of your chosen pharmacy
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Lifestyle

Your Height

What unit of measurement are you using?: *
Conversion from Feet & Inches to Centimetres

Your Weight

What unit of measurement are you using?: *
Conversion from Stones & Pounds to Kilograms
Please add any other relevant information you think the doctor should be aware of.
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Previous Details
Are you registering your child with a GP for the first time in the UK?: *
Have you recently moved to the UK: *
Please include postcode
Are you returning from abroad?: *
If you are from abroad
Please use this date format: DD/MM/YYYY
Refugee: *
Asylum Seeker: *
Are you returning from abroad? : *
If you are returning from abroad

This assumes that you have previously been registered with the NHS in the UK

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Supplementary Questions - If you are not a resident in the UK, but visiting or moving to the UK
New Patient Registration

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, nationals of countries outside the European Economic Area must also have the status of ‘indefinite 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 leaflet, available at reception. Alternatively for more information go to the NHS Website

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.

Please select one of the following statements:: *
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European Economic Area (EEA) Country
Do you (as the legal guardian) 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?:
Do you (as the legal guardian) have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC)?:

Please Note

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

Please enter the details from your EHIC or PRC below.

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Carers

A carer is anyone, including children and adults who looks after a family member, partner, or friend who needs help because of their illness, frailty, disability, a mental health problem or an addiction and cannot cope without their support.

  • This is different from normal parenting duties for a child
Does your child have a carer?: *
UK number only
If a company of organisation, please indicate which above.
Do you give us permission to discuss your Child's medical record with their carer?: *
Does you child care for someone?: *
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Please upload a copy of the following documents

  • You can upload a document, photo or scan
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
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What happens to my information?

  • Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.
  • We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.
  • To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.
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Privacy Consent

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