New Patient Registration for Under 16 Year Olds • Friarsgate Practice

Preliminary Questions

Is this your first registration with a GP Practice in the UK? *YesNo

Are you from abroad? *YesNo

Date you first came to live in the UK *

Patient Details

First Name *

Middle Name

Surname *

Previous Surnames

Date of Birth *

Gender *MaleFemale

NHS Number *

Home Address *

Postcode *

Your Previous address in the UK (including postcode) *

Town of birth *

Country of birth *

Home Phone Number

Mobile Phone Number *

Email Address

Patient’s Previous Details

Please help us trace your previous medical records by providing the following information.

Your Previous address in the UK (including postcode) *

Name of your previous doctor while at that address *

Address of previous doctor *

Parent/Guardian Details

Allergies

Do you have any allergies? *YesNo

Please specify what you are allergic to, what happens and when you had your first reaction *

Language

What is your child’s main spoken language? *

Does your child have any problems reading English? (school age children only) *No problemsSome problemsA lot of problems

Does your child have any problems speaking English? *No problemsSome problemsA lot of problems

If English is not your child’s main spoken language or yours, do you need an interpreter (someone to help with language) when you visit the doctor? *YesNo

Medical History

Does your child have any long-term illness, health problem or disability? *YesNo

If yes, please provide more information *

Electronic Prescribing

The Electronic Prescription Service (EPS) sends electronic prescriptions from GP practices to pharmacies. Eventually EPS will remove the need for most paper prescriptions.

Which pharmacy would you like us to send your prescription too? *

Do you take repeat medications? *YesNo

Which medications do you currently receive on repeat prescription? Please include dosages. *

Your Data

If you do NOT wish the NHS to share data from your health records for the purposes of research and planning, please opt out on the NHS website.

Summary Care Records (SCR)

These are an electronic record of important patient information, created from GP medical records. They can be seen and used bu authorised staff only; in other areas of the health and care system involved in the patients care.

To Opt Out, visit www.digital.nhs.uk/scr

NHS Organ Donor Registration

For more information on organ donation, please visit: www.organdonation.nhs.uk

NHS Blood Donor Registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: www.blood.co.uk or call direct on 03001232323

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.

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.

Signature of patient *

Signature on behalf of patient *

Date *

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

New Patient Registration – Under 16 years

Preliminary Questions

Patient Details

Patient’s Previous Details

Parent/Guardian Details

Allergies

Ethnicity

Language

Medical History

Electronic Prescribing

Your Data

Summary Care Records (SCR)

NHS Organ Donor Registration

NHS Blood Donor Registration

What happens to my information?

Privacy Policy

New Patient Registration – Under 16 years

Preliminary Questions

Patient Details

Patient’s Previous Details

Parent/Guardian Details

Allergies

Ethnicity

Language

Medical History

Electronic Prescribing

Your Data

Summary Care Records (SCR)

NHS Organ Donor Registration

NHS Blood Donor Registration

What happens to my information?

Privacy Policy

Cookies