Child New Patient Registration

Child's Details

Title *

Mr

Miss

Ms

Other

Please specify:

Surname: *

Previous Surnames:

First Name(s) *

Sex: *

Male

Female

Indeterminate

NHS Number:

Town and Country of birth: *

Home Address: *

Postcode: *

Name of school (if applicable):

Parent / Guardian 1 Details

Full Name: *

Date of Birth: *

Relationship to child: *

Address (including postcode):

Home or Mobile Phone Number: *

Please note that your email address will be saved as part of your contact details in your medical records. We may contact you via your email address if you become locked out of your online account and need your password sent, or to send you health questionnaires.

In future we may send you clinical letters via email instead of as a posted letter for speed and to reduce our carbon footprint. You can opt-out of this by telling the Practice.

Can we contact you by text? *

Yes

No

Can we contact you by email? *

Yes

No

Parent / Guardian 2 Details

Full Name:

Date of Birth:

Relationship to child:

Address (including postcode):

Home or Mobile Phone Number:

Email Address:

Please note that your email address will be saved as part of your contact details in your medical records. We may contact you via your email address if you become locked out of your online account and need your password sent, or to send you health questionnaires.

In future we may send you clinical letters via email instead of as a posted letter for speed and to reduce our carbon footprint. You can opt-out of this by telling the Practice.

Can we contact you by text?

Yes

No

Can we contact you by email?

Yes

No

Ethnicity

Please state:

Do you speak English?

Yes

No

Do you read English?

Yes

No

First Language:

Previous Details

Previous address in UK:

Please include postcode.

Name and address of previous GP:

If you are from abroad

Registering with the NHS for the first time in the UK

Date you came to live in the UK:

Please use this date format: DD/MM/YYYY.

If you are returning from abroad

Previously been registered with the NHS in the UK

Date you left the UK:

Please use this date format: DD/MM/YYYY.

Date you returned to the UK:

Please use this date format: DD/MM/YYYY.

Supplementary Questions

I am not ordinarily a resident in the UK

Ordinarily Resident

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.

Sharing Your Health Care Records and Information

Your patient record will be held securely and confidentially on our electronic system. If you require treatment in another NHS healthcare setting such as an Emergency Department or Minor Injury Unit, those treating you would be better able to give you appropriate care if some of the information from the GP practice were available to them.

This information is your summary care record.

Please view the Summary Care Record page so you can make informed decisions on the next section.

NHS Summary Care Record

Your choice for Summary Care Record: *

I would like my information shared through the Summary Care Record

I would like a Summary Care Record with additional information added

I do not want my information shared through the Summary Care Record

Your choice for Gloucestershire shared health and social care information (JUYI/EMIS Shared) (Used locally across Gloucestershire)

Gloucestershire shared health and social care information (JUYI): *

I would like my information shared through the Gloucestershire shared health and social care information project

I do not want my information shared through the Gloucestershire shared health and social care information project

Enhanced Data Sharing Model (SystmOne Clinical System)

Enhanced Data Sharing Model (SystmOne Clinical System) - Sharing Out *

I would like my information shared out to SystmOne healthcare providers

I do not want my information shared out to SystmOne healthcare providers

Enhanced Data Sharing Model (SystmOne Clinical System) - Sharing In *

I want my GP practice to view data that is recorded at another SystmOne NHS organisation that may care for me

I do not want my GP practice to view data that is recorded at another SystmOne NHS organisation that may care for me

Signature: *

Date:

On behalf of patient: Please state full name: *

On behalf of patient: Please state relationship: *

Carers

Do you have a carer?

Yes

No

Are you a young carer for someone?

Yes

No

Name of carer:

Phone Number:

Address:

Do you give us permission to discuss your medical record with your carer?

Yes

No

Tell us whether you accept cookies

Child's Details

Parent / Guardian 1 Details

Parent / Guardian 2 Details

Ethnicity

Previous Details

If you are from abroad

If you are returning from abroad

Supplementary Questions

Ordinarily Resident

European Economic Area (EEA) Country

EHIC/PRC

S1 Form

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

Sharing Your Health Care Records and Information

NHS Summary Care Record

Your choice for Gloucestershire shared health and social care information (JUYI/EMIS Shared) (Used locally across Gloucestershire)

Enhanced Data Sharing Model (SystmOne Clinical System)

Carers

Wilson Health Centre Update