Child New Patient Registration

Child's Personal Details

Title: *

Master

Ms

Miss

Gender: *

Male

Female

Child's Surname: *

Child First Names: *

Previous Surnames:

Date of Birth: *

Please use date format DD/MM/YYYY.

NHS Number: *

Town & Country of Birth: *

Current Postcode: *

Current Address: *

Contact Number: *

Email Address: *

Please specify whose above email this is: *

e.e Parent, Guardian, Child etc

Note, we use the mobile number for text messages. Text messages will automatically cease when the Child is 11 years old.

Name of Parent(s)/Carers *

Has Legal/Parental Responsibility? *

Yes

No

Next of Kin?

Yes

No

If not the above, name of person with legal responsibility:

Contact details of person with legal responsibility:

Does the child have any special communication/mobility needs? *

Yes

No

Please specify (other):

Is the child currently:

A refugee

An asylum seeker

Is the child in care?

Yes

No

Is the child a 'Looked After Child'?

Yes

No

In what capacity? *

Temporary

Permanent

Is the child home educated? *

Yes

No

Name of Social Worker:

Social Worker's Phone Number:

Name of child's nursery/school:

Has the child or family either currently or in the past been known to Children’s Services? *

Yes

No

Name of Social Worker:

Social Worker's Phone Number:

Required Information:

Is your child looking after someone at home? *

Yes

No

If so, who?

Please tell us if the child is looking after someone who is ill, frail, disabled, has mental health/emotional support needs or substance misuse problems.

What is the adult’s relationship to the child? *

Do you think the child would like additional support as a young carer?

Yes

No

Is the child known to services such as Young Carers?

Yes

No

Is the child being privately fostered (see definition below)? *

Yes

No

Are children's services aware?

Yes

No

Private fostering is an arrangement whereby a child under the age of 16 (or 18 if the child has a disability) (S.66 Children Act 1989) is placed for 28 days or more in the care of someone who is not the child’s parent(s) or a ‘connected person’. Private foster carers can be from the extended family, e.g. a cousin or a great aunt, but cannot be a relative as defined under the Children Act 1989, section 105:‘A relative under the Children Act 1989 is defined as a ‘grandparent, brother, sister, uncle or aunt (whether full blood or half blood or by marriage or civil partnership) or step-parent’.

Please provide carer’s name: *

Carer's relationship to child: *

Contact details of carer: *

Please help us trace the child’s previous medical records by providing the following information:

Your previous address in the UK: *

Please include postcode. If you do not have a previous address, please state 'N/A'.

Name of previous Doctor while at that address: *

If you do not have a previous GP, please state 'N/A'.

Surgery Name and Address of previous Doctor: *

Please include postcode. If you do not have a previous GP, please state 'N/A'.

If you are from abroad:

Your first UK address where registered with a GP:

Please include postcode.

If previously resident in UK date of leaving:

Date you first came to the UK:

If registering a child under 5:

I wish the child above to be registered with (Waterside Medical Practice) for Child Health Surveillance

Supplementary Questions

I am not ordinarily a 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, 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 from your GP practice. Alternatively for more information go to www.nhs.uk/visitingengland.

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:

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 requested

I 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.

Signature: *

Print Name:

On behalf of:

Relationship to patient:

Date:

European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea

Do you 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?

Yes

No

Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?

Yes

No

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.

EHIC/PRC

Please enter the details from your EHIC or PRC below.

Country Code:

3. Name:

4. Given Names:

5. Date of Birth:

6. Personal Identification Number:

7. Identification number of the institution:

8. Identification number of the card:

9. Expiry Date:

PRC validity period - from:

PRC validity period - to:

S1 Form

Do you have an S1 Form?

I have an S1 form (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 The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

Child’s Personal Medical History:

If under 5 years old, type of Birth:

(eg normal, forceps, caesarean)

Has your child ever suffered from any important medical illness, operation or admission to hospital?

Yes

No

Condition:

Year Diagnosed:

Ongoing?

Yes

No

Condition:

Year Diagnosed:

Ongoing?

Yes

No

Condition:

Year Diagnosed:

Ongoing?

Yes

No

Family Medical History:

Have any close relatives (father, mother, sister, brother only) ever suffered from:

Please tell us who and what age they were when diagnosed:

Child's Immunisations

Tetanus

Date:

Whooping Cough

Date:

Polio

Date:

HiB

Date:

Measles

Date:

MMR

Date:

BCG (TB)

Date:

Meningitis

Date:

Booster: Tetanus

Date:

Booster: Diphtheria

Date:

Booster: Polio

Date:

Booster: MMR

Date:

Child’s List of Current Medication:

Dosage:

Child’s Allergies:

Please list any allergies the child has to any drugs/medications or if known egg allergy or peanut allergy.

Name of Medication:

What was the problem or upset?

About the Child

Please specify:

Religion of Child:

Please advise if you feel your child’s religion will affect any treatment received:

Yes

No

Child's Main Language: *

Does the child need an interpreter?

Yes

No

Data Sharing Consent Choices:

To maintain continuity of clinical care, we upload certain medical information so that it is available to other healthcare organisations (eg Emergency Departments). Please read the accompanying leaflet which details what part of your record is extracted and how it is used to help other NHS organisations.

Where you have provided information on how to contact you, can you confirm you are happy for the practice to contact you by the following:

By email:

Yes

No

This will be to send you letters, the practice newsletter and the like.

By text:

Yes

No

This will be to send you reminders of appointments via text.

I confirm that the information that has been provided is true to the best of my knowledge.

Signed: *

Date:

*

Signature on behalf of patient

Signature of patient

Name of person signing: *

Relationship to Child: *

Any additional information:

Child Registration

Child's Personal Details

Required Information:

Please help us trace the child’s previous medical records by providing the following information:

If you are from abroad:

If registering a child under 5:

Supplementary Questions

European Economic Area (EEA) Country

EHIC/PRC

S1 Form

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

Child’s Personal Medical History:

Family Medical History:

Child's Immunisations

Child’s Allergies:

About the Child

Data Sharing Consent Choices:

Hay Fever

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Child New Patient Registration

Child Registration

Child's Personal Details

Required Information:

Please help us trace the child’s previous medical records by providing the following information:

If you are from abroad:

If registering a child under 5:

Supplementary Questions

European Economic Area (EEA) Country

EHIC/PRC

S1 Form

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

Child’s Personal Medical History:

Family Medical History:

Child's Immunisations

Child’s Allergies:

About the Child

Data Sharing Consent Choices:

Hay Fever