Online formFields marked * are required. This form is processed by the practice's website form plugin; in this static preview it is display-only. Title *SelectMrMrsMissMs Full Name * Maiden name / Mothers name if different Gender *MaleFemaleOther Telephone number * We will use this to send appointment reminders and health promotion details. Please click here to give your consent for this: * We will use this to send appointment reminders and health promotion details. Please click here to give your consent for this: Date of Birth * NHS number if known Email Address * Address * Postcode * How would you prefer us to contact you? *LetterEmailSMS (text)Phone Next of Kin Relationship with patient Kin's tel. number Country Town Borough (*If born in London) Please list other residents of your home who are registered with us Name of the registered person Registered person's Date of Birth NHS No. * Town of Birth * Country of birth * Home Address * Please help us trace your previous medical records by providing the following information Your previous address in UK Name of previous doctor while at that address Address of previous doctor If you are from abroad Your first UK address where registered with a GP Date of leaving (If previously resident in UK) Date you first came to live in UK If you are returning from the Armed Forces Address before enlisting Service or Personnel number Enlistment date * If you are registering a child under 5 I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance If you need your doctor to dispense medicines and appliances*I live more than 1 mile in a straight line from the nearest chemistI would have serious difficulty in getting them from a chemist *Not all doctors are authorised to dispense medicines NHS Organ Donor registration I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death. Please tick as appropriate Kidneys Heart Liver Corneas Lungs Pancreas Any part of my body I do not want to join the NHS Organ Donor Register Confirm your consent to organ donation Confirm your consent to organ donation NHS Blood Donor registration I would like to join the NHS Blood Donor Register as someone who may be contacted and would be pre p a red to donate blood Check this if you have given blood in the last 3 years For more information, please ask for the leaflet on joining the NHS Blood Donor Register My preferred address for donation is: (only if different from above, e.g. your place of work) * Postcode Looking After A Family Member Is your child looking after someone?Let 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 * Yes No Is someone looking after your child?Let us know if a family member, friend or neighbour looks after your child. * Yes No Carer's Name Carer's Relationship with your child Carer's Telephone No. Is your child’s carer registered with us? Yes No Carer's Address Your Child’s Religion (Please State here) * Your Child’s Ethnic Origin *Black Caribbean/BritishBlack African /BritishIndian / British IndianPakistani / British PakistaniBangladeshi / British BangladeshiArabicChineseWhite (UK)White (Irish)White (Other)Other Black BackgroundOther Asian BackgroundOther Mixed BackgroundOtherEthnic Category Refused Does your child need an Interpreter? *YesNo If yes, which language? Does your child need help with mobility/hearing/speaking?(Select all that apply) Wheelchair Walking aid Hearing aid British sign language (BSL) Makaton sign language Lip reading Large print Braille Other If Other (Please state) Is your child currently? *HomelessA RefugeeAn Asylum Seeker Is your child housebound? *YesNo Are there any serious diseases that affect your child’s parents, brothers or sisters? State the family member if have Diabetes State the family member if have Asthma State the family member if haveThyroid disorder State the family member if have Stroke State the family member if have COPD State the family member if have Heart Attack under age of 60 State the family member if have Cancer (Specify type) State the family member if have High Blood pressure Please state if someone in your family have any other important illness Please state any allergies and sensitivities that your child has to medicines, food & dressings Please state any mental disabilities your child have Are you able to administer your own medicines?YesNo If no please give details, e.g. swallowing or opening containers What chronic medical conditions has your child had? Date of Diagnosis What operations has your child had? Date of operation/s What injuries has your child had? Date of injury/s Please list any tablets, medicines or other treatments your child is currently taking / undertaking: Immunisation for age: 2 Months 1st Diphtheria, Tetanus, Pertussis Date of 1st Diphtheria, Tetanus, Pertussis Immunisation taken from GP Surgery Private Abroad 1st Polio Date of 1st Polio Immunisation taken from GP Surgery Private Abroad 1st HIB Date of 1st HIB Immunisation taken from GP Surgery Private Abroad 1st Pneumococcal Vaccine Date of 1st Pneumococcal Vaccine Immunisation taken from GP Surgery Private Abroad 1st Rotavirus Date of 1st Rotavirus Immunisation taken from GP Surgery Private Abroad Immunisation for age: 3 Months 2nd Diphtheria, Tetanus, Pertussis Date of 2nd Diphtheria, Tetanus, Pertussis Immunisation taken from GP Surgery Private Abroad 2nd Polio Date of 2nd Polio Immunisation taken from GP Surgery Private Abroad 2nd HIB Date of 2nd HIB Immunisation taken from GP Surgery Private Abroad 1st Meningitis C Date of 1st Meningitis C Immunisation taken from GP Surgery Private Abroad 2nd Rotavirus Date of 2nd Rotavirus Immunisation taken from GP Surgery Private Abroad Immunisation for age: 4 Months 3rd Diphtheria, Tetanus, Pertussis Date of 3rd Diphtheria, Tetanus, Pertussis Immunisation taken from GP Surgery Private Abroad 3rd Polio Date of 3rd Polio Immunisation taken from GP Surgery Private Abroad 3rd HIB Date of 3rd HIB Immunisation taken from GP Surgery Private Abroad 2nd Pneumococcal Vaccine Date of 2nd Pneumococcal Vaccine Immunisation taken from GP Surgery Private Abroad 2nd Meningitis C Date of 2nd Meningitis C Immunisation taken from GP Surgery Private Abroad Immunisation for age: 12 Months Hib/Men C Booster Date of Hib/Men C Booster Immunisation taken from GP Surgery Private Abroad Immunisation for age: 13 Months MMR (Measles, Mumps, Rubella) Date of MMR (Measles, Mumps, Rubella) Immunisation taken from GP Surgery Private Abroad 3rd Pneumococcal Vaccine Date of 3rd Pneumococcal Vaccine Immunisation taken from GP Surgery Private Abroad Immunisation for age: 3½ to 5 years MMR Booster (Measles, Mumps, Rubella) Date of MMR Booster (Measles, Mumps, Rubella) Immunisation taken from GP Surgery Private Abroad Pre- School Booster Diphtheria, Tetanus, Pertussis & Polio Date of Pre- School Booster Diphtheria, Tetanus, Pertussis & Polio Immunisation taken from GP Surgery Private Abroad Sharing Your Child'd Medical Record Medical Record Sharing allows your child’s complete GP medical record to be made available to authorised healthcare professionals involved in their care. You will always be asked your permission before anybody looks at your child’s shared medical record. If you don’t want to share your child’s GP record locally tick here Summary Care Records containsdetails of your child’s key health information – medications, allergies and adverse reactions. They are accessible to authorised healthcare staff in A&E Departments throughout England. You will always be asked your permission before anybody looks at your child’s Summary Care Record. If you 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 services, 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 services and is shared with third parties for research purposes. I wish to OPT OUT from my child’s Personal Confidential Data being shared outside their GP practice I wish to OPT OUT from my child’s Personal Confidential Data being shared with third parties First Parent's Name * Second Parent's Name * Name of person with legal parental responsibility * Name of school attended * Parent / Guardian permission given * Permission given for someone other than a Parent/Guardian to accompany your child to an appointment? Permission giving person's name * Person's Relationship with Child * Send
