New Patient Registration Form - Child
Please complete all pages in full using block capitals

Named accountable GP: 

1. Background Details	

Your Child Details	
NHS Number		If you have had a previous GP then you will find this on letters/prescriptions or at www.nhs.uk/find-nhs-number	
	I do not know my NHS number 	
Child Name		
Previous Surname ( if applicable)		
Gender		Title	 Master    Miss	
Which of the following best describes how you think of yourself?	 Non-binary       Female         Male          Prefer not to say        Unable to answer	
Is your gender the same as the sex you were assigned at birth?	 Yes
 No	Prefer not to say
Unable to answer	
Address		Date of Birth		
		Town & Country of birth	If London, please include borough

		Home Telephone		
Has the patient been registered in the NHS before?          
	 Yes       No
	
If no, please state date entered UK		
If previously resident in the UK, date of leaving:                                                 Date of return:	

Parent or Guardian Details	
Your Name		
Relationship		
Address		Home Telephone	
	
		Work Telephone	
	
Mobile Telephone	I consent to be contacted* by SMS on this number: 	
Email	I consent to be contacted* by email at this address: 	
Family Registered With Us		
 * It is your responsibility to keep us updated with any changes to your telephone number, email & postal address.

Other Details	
Previous address				
Previous GP	Name:

Address:
	
Ethnicity	 White (UK)
 White (Irish) 
 White (Other) 	 Black Caribbean
 Black African
 Black Other	 Bangladeshi
 Indian 
 Pakistani	 Arabic
 Chinese
 Other	
Housing	 Sheltered House	 Asylum Seeker	 Refugee		
Overseas Visitor	 Yes	 European Health Insurance Card Held (please bring details with you)	
Armed Forces	 Family Member				

Communication Needs	
Language	What is your main spoken language?

Do you need and interpreter?    Yes     No	
Communication	Do you have any communication difficulties?   Yes         No
If Yes please identify below	
	 Hearing aid
 Lip reading	 Large print
 Braille	 British Sign Language
 Makaton Sign Language     Guide dog	

Carer Details	
Are you a carer?	 Yes – Informal / Unpaid Carer	 Yes – Occupational / Paid Carer	 No	
Do you have a carer?	 Yes    	Name*:	Tel:	Relationship:	
* Only add carer’s details if they give their consent to have these details stored on your medical record

If you are applying on behalf of a child who is in Foster care/Residential care/Kinship care/ or who is not your child	
who has parental or legal responsibility for the child?	
 You as the legal/guardian/adoptive parent	 Other (please specify)	
Name:      	Contact Number:      	
Evidence of parental responsibility (birth certificate/social care information):
     	
If you are the parent/guardian/foster carer/kinship carer but cannot consent, please detail below who can	
Name:      	Contact Number:      	
Relationship to child:      	

Looked after Children	
If a child, are they looked after?		 Yes	 No
If Yes, under what arrangements:
 Section 20-Voluntary Care			 Subject to an Interim Care Order
 Subject to a Full Care Order			 Placed for adoption
 Unaccompanied Asylum Seeker
 Private arrangement/Private Fostering/Informal arrangement 
(please note you have a duty to notify social care of this arrangement)
What is Private Fostering? 
A private fostering arrangement is one that is made without the involvement of the Local Authority to look after a child under the age of 16 (or under 18 if disabled) by someone other than a parent or close relative, for 28 days or more and can include those living with extended family members. So, this could be a child living with people as stated below:
Private Fostering includes a child living with: godparents, great-grandparents, great aunts or uncles, family friends, step parents where a couple isn’t married or in a civil partnership, cousins, a host family which is caring for a child from overseas while they are in education here.
Private Fostering does not include a child living with: Brothers. sisters, grandparents, aunts, uncles, step parents where a couple is married or in a civil partnership, mother, father, children and young people who are being looked-after by the Local Authority.	
Name of School or Nursery:      		 Home schooled
Does the child have a social worker?	 Yes	 No		Name of social worker:      
Are there any other Agencies involved in their care?	 Yes	 No
Contact Details:      	

2. Medical History	

Vaccinations	

Has your child had all their routine vaccinations?                     Yes	 No

Did your child get all their routine vaccinations in the UK?       Yes	 No
If no, please provide a copy of the vaccination history with this registration form.

Medical History	
Has your child suffered from any of the following conditions?	
 Asthma	 Depression	 Diabetes	 Epilepsy	
Any other conditions, operations or hospital admission details:

If your child is currently under the care of a Hospital or Consultant outside our area, please tell us here:

	

Family History	
Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent
	
 Asthma:
 COPD:
 Epilepsy:
 Heart Disease:
 Stroke:
 Blood Pressure:	 Diabetes:
 Kidney Disease:
 Liver Disease:
 Depression:
 Thyroid:
 Cancer:
	
Other:

	

Allergies	
Please record any allergies or sensitivities below

Current Medication	
Please attach if possible a copy of your repeat prescription request and include any other medication you may be taking which does not appear on your list. PLEASE NOTE AN APPOINTMENT WITH THE GP MAY BE NECESSARY FOR A MEDICATION REVIEW. 

3. Further Details	
Electronic prescribing	
If you would like your child’s prescriptions to go electronically, please provide details of the pharmacy you would like to use:	Pharmacy: 	

Parent or Guardian Signature	
Signature	

I confirm that the information I have provided is true to the best of my knowledge	
Name		
Date		

4. Online Access to Your Health Record	
We offer an online service which will enable you to order prescriptions, book appointments and have access to aspects of your medical record. We require photo ID (passport, driving licence) to enable access. Please ask a receptionist for details.	

5. Sharing Your Health Record	

Your Health Record	
Sharing Out
Do you consent to your GP Practice sharing your Child’s health record with other organisations who care for them?

     Yes  (recommended option)
     No

Sharing In
Do you consent to your GP Practice viewing your Child’s health record from other organisations that care for them?

     Yes  (recommended option)
     No	

Your Summary Care Record (SCR)	
Do you consent to your child having an Enhanced Summary Care Record with Additional Information?

     Yes  (recommended option)
     No	

Parent or Guardian Signature	
Signature		
Name		
Date		

Data Sharing for Research (not for direct care)	

Please note:

You can also tell your GP practice if you do not want your child’s confidential patient information held in their GP medical record to be used for purposes other than their individual care. This is commonly called a Type 1 opt-out. This opt-out request can only be recorded by your child’s GP surgery.

I do not wish identifiable data about my child to leave the practice                              (For practice use only - XaZ89)

Name: ______________________________________                         Signature: ____________________________

Date: __________________________

You can also object to any information containing data that identifies your child leaving the NHS Digital secure environment. This is the National Data Opt-out and can no longer be set by your child’s GP. This includes information from all places where your child receives NHS care, such as hospitals. If you object, confidential information will not leave NHS Digital and will not be used, except in very rare circumstances for example in the event of a public health emergency.

You can change your choice at any time.
To find out more or to make your choice visit: nhs.uk/your-nhs-data-matters or call 0300 303 5678	

Sharing Your Health Record

What is your health record?
Your health record contains all the clinical information about the care you receive.  When you need medical assistance it is essential that clinicians can securely access your health record. This allows them to have the necessary information about your medical background to help them identify the best way to help you. This information may include your medical history, medications and allergies.

Why is sharing important?
Health records about you can be held in various places, including your GP practice and any hospital where you have had treatment. Sharing your health record will ensure you receive the best possible care and treatment wherever you are and whenever you need it. Choosing not to share your health record could have an impact on the future care and treatment you receive. Below are some examples of how sharing your health record can benefit you:

•	Sharing your contact details 	This will ensure you receive any medical appointments without delay
•	Sharing your medical history 	This will ensure emergency services accurately assess you if needed
•	Sharing your medication list	This will ensure that you receive the most appropriate medication
•	Sharing your allergies		This will prevent you being given something to which you are allergic 
•	Sharing your test results 	This will prevent further unnecessary tests being required

Is my health record secure?
Yes. There are safeguards in place to make sure only organisations you have authorised to view your records can do so. You can also request information regarding who has accessed your information from both within and outside of your surgery.

Can I decide who I share my health record with?
Yes. You decide who has access to your health record. For your health record to be shared between organisations that provide care to you, your consent must be gained.

Can I change my mind?
Yes. You can change your mind at any time about sharing your health record, please just let us know.

Can someone else consent on my behalf?
If you do not have capacity to consent and have a Lasting Power of Attorney, they may consent on your behalf. If you do not have a Lasting Power of Attorney, then a decision in best interests can be made by those caring for you.

What about parental responsibility?
If you have parental responsibility and your child is not able to make an informed decision for themselves, then you can make a decision about information sharing on behalf of your child. If your child is competent then this must be their decision.

What is your Summary Care Record?
Your Summary Care Record contains basic information including your contact details, NHS number, medications and allergies. This can be viewed by GP practices, Hospitals and the Emergency Services. If you do not want a Summary Care Record, please ask your GP practice for the appropriate opt out form. With your consent, additional information can be added to create an Enhanced Summary Care Record. This could include your care plans which will help ensure that you receive the appropriate care in the future.

How is my personal information protected?
Queens Avenue Surgery will always protect your personal information. For further information about this, please see our Privacy Notice on our website or please speak to a member of our team

For further information about your health records, please see: www.nhs.uk/NHSEngland/thenhs/records
For further information about how the NHS uses your data for research & planning and to opt-out, please see: 
www.nhs.uk/your-nhs-data-matters