Child New Patient Registration Please complete the form below for each person that is registering at the practice. * = Mandatory field Child New Patient Registration Title: * Master Miss Other Please specify: Surname: * Previous Surnames: First Name(s): * Preferred Name (e.g. Jennie vs Jennifer): Date of Birth: * Please use this date format: DD/MM/YYYY. Gender * Male Female NHS Number: Town and Country of Birth: * Date they entered the UK (if applicable) Main Language: Do they need a translator? Yes No Home Address (including postcode): * Telephone Number: * Mobile Number: School / Nursery: Email Address: * Previous Details Previous Address: Previous GP Surgery: Previous School: Next of Kin and Contact Details - At least one parent/carer/guardian must be registered at the practice Parent/Carer/Guardian 1 Name: * Relationship: * Contact Number: * Email Address (if different from above): Are you registered at the practice? Yes No Do you live at the address above? Yes No Parent/Carer/Guardian 2 Name: Relationship: Contact Number: Email Address: Are you registered at the practice? Yes No Do you live at the address above? Yes No We will use these contact details to send reminders about appointments, reviews and other services which may be of benefit in your child's care. Do you consent to the Surgery sending text messages to your mobile? * Yes No Do you consent to the Surgery sending messages to you by email? * Yes No Do you consent to the Surgery leaving messages on your phone? * Yes No We will not leave detailed messages on your phone but may ask you to contact us or leave a simple message if we do not need to speak to you. Please select your preferred choice of contact: * Text Phone Email Post Allergies Does the child have any allergies? * Yes No Please specify what you are allergic to, what happens and when you had your first reaction: * Record Sharing Thank you. This information will be shared with The Primary Health Care Team Systm One Sharing Locally for the purposes of the Local Shared Electronic Record (CHIE) and the OOH Hub for direct health care * Opt in Opt out Summary Care Record Nationally for the purposes of National Shared Electronic Record (SCR) for direct health care * Opt in Opt out For HV / SHN Use ONLY Information Received: Records Requested from: Information sent to Child/School Health: Electronic Prescription Service (EPS) The Electronic Prescription Service (EPS) is a NHS service that allows us to send your prescription(s) directly to your chosen pharmacy. This paper-free prescription service means that you do not have to come into the surgery to collect your prescription. We encourage all patients to register for this free service. Would you like to register for EPS? * Yes No EPS Registration I would like to have my prescription sent electronically. My chosen Pharmacy is: Please select a pharmacy... Peartree Pharmacy, 110 Peartree Lane Codicote Pharmacy, 123 High Street Boots, 65 Moors Walk Boots, 31 Cole Green Lane The Village Pharmacy, 62 High Street Tesco, Mount Pleasant Waitrose, Bridge Road Lloyds Pharmacy, 9 Shoplands Lloyds Pharmacy, 84 Haldens Sainsbury's Pharmacy, 44 Church Rd Boots, 126 Peartree Lane Boots, 43-45 Queensway care2homes Pharmacy, The Polaris Centre Boots, 47 Town Centre Boots, 17 Bircherley Green Boots, The Howard Centre Other Not sure what your closest pharmacy is? Use the NHS Find a Pharmacy tool. Other Pharmacy Name: * Pharmacy Address: * Pharmacy Postcode: * Ethnicity and Religion Having information about patients’ ethnic groups would be helpful for the NHS so that it can plan and provide culturally appropriate and better services to meet patients’ needs. If you do not wish to provide this information you do not have to do so. Ethnic Group: * White British White Irish Any Other White background White and Black Caribbean White and Black African White and Asian Indian Pakistani Bangladeshi Any Other Asian Background Black Caribbean Black African Any Other Black Background Chinese Other Ethnic Group I do not wish to state Please specify: * Religion: Consent * I consent that the information given is true to the best of my knowledge. Signed: * Date: Relationship to child: *
