New Patient Questionnaire Under 16 - The Red House Surgery

Non-urgent advice: Information

If your child is new to the UK: please complete the Immunisation History section, or upload documents via: SEND DOCUMENT TO YOUR GP with the subject line: IMMUNISATION LIST FOR NEW CHILD

If your child was born in the UK: please bring their RED BOOK to the surgery after you have completed the registration form. Please mark it clearly with the name that matches the registration form you submitted. Failure to do this may result in information being missed and a delay in updating their record.

New born baby, please contact the surgery to arrange the baby check and immunisation appointment.

Immunisation History

I will drop the Red Book at the Surgery Optional

I will complete the Immunisation History Optional

I will email my immunisation list Optional

I am a new born baby without immunisations Optional

Title

Miss

Other

NHS Number Optional

First Name

First

Last Name

Last

Date of Birth

DD slash MM slash YYYY

Sex

Male

Female

Ethnicity

First Spoken Language

Town and Country of Birth

Address (UK Only)

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

Telephone Number (UK Only)

Landline (UK Only) Optional

Email Address Optional

Consent to receive SMS notification for clinical services

Yes Optional

No Optional

Consent to receive EMAIL notification for clinical services

Yes Optional

No Optional

Please help us trace your previous medical records by providing the following information. N/A – If this: is the first registration with the GP:

Your previous address in the UK

Street Address Address Line 2 City Postcode

Name of previous GP practice while at that address

Address of previous doctor

Street Address Address Line 2 City Postcode

Are you from Abroad?

Yes Optional

No Optional

If you are from abroad:

Your first address where registered with a GP

Street Address Optional Address Line 2 Optional City Optional ZIP / Postal Code Optional

If previously resident in UK, date of leaving

Day Optional

Month Optional

Year Optional

Date you first came to live in the UK

Day

Month

Year

Resident in the UK

I am not ordinarily a resident in the UK Optional

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 Optional

No Optional

Demographics

Marital Status

Are you British Sign Language user?

Yes

Disability

Do you have an impairment, health condition or learning difference that has a substantial or long term (over a year) impact on your ability to carry out day to day activities? (Tick all that apply)

No known impairment, health condition or learning difference Optional

A long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, asthma, or epilepsy Optional

A mental health impairment, such as depression, schizophrenia or anxiety disorder Optional

A physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches Optional

A learning difficulty Optional

Neuro-diverse e.g. dyslexia, dyspraxia or AD(H)D Optional

Deaf or hearing impaired Optional

Blind or have a visual impairment uncorrected by glasses Optional

An impairment, health condition or learning difference that is not listed above Optional

Prefer not to say Optional

Do you have any specific information or communication needs? If so, please specify how we can meet these for you (e.g. large print, Braille, easy read communications) Optional

If you are filling this form on behalf of a child the Surgery will need to check that you have the authority to do so. Please complete your details below.

Full name

First Last

Relationship to patient (as named on this form) Optional

Contact Number Optional

Full name of parents / guardian / person with parental responsibility

Guardian Details

Name

First Last

Name

First Optional Last Optional

Are there any other children in the family?

Yes Optional

No Optional

Please tell us about other children in the family Optional

Allergies

Do you have any allergies?

Yes

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

Please include dates

Immunisation Histor

Please list any immunisations/vaccinations you have had Optional

Please include dates.If you received any covid vaccination abroad, please state: Date, vaccine, batch number, which arm, dose and from which country

Important Registration Information

For anyone aged 16 and over, we offer online services for appointment booking and repeat prescription ordering. This is the quickest and easiest way to order your medication. Once registered, you will also be able to view your summary record, detailing current medication, allergies and vaccinations.

You will soon receive an email from the practice with your log in details.

These are confidential: It is your responsibility to ensure they can be received securely by email.

Prescriptions are sent electronically to your nominated pharmacy. We will automatically nominate the pharmacy closest to your post code as part of your registration. If you prefer to use a different chemist please contact the practice to sign up for the Electronic Prescribing Service.

Summary Care Record

This record will contain summary information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely.

Your Summary Care Record will be available to authorised healthcare staff providing you with care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill away from home, healthcare staff treating you will have immediate access to important information about your health.

Do you consent to having a Summary Care Record?

YES – Express consent for medication, allergies and adverse reactions only. OR Optional

YES – Express consent for medication, allergies, adverse reactions AND additional information. Optional

NO – I do not want a summary care record. Optional

Your Medical Information – Sharing Your Data

Under the General Data Protection Regulations (GDPR), we have a responsibility to keep your medical records confidential. We need your consent to share this with other authorised health professionals involved in your care or in planning your care. You can find more information on the website at www.nhs.uk/your-nhs-data-matters.

Please see the privacy notice on our website for more information on how your data is held and used by the practice.

The NHS wants to make sure you and your family has the best care now and in the future. Your health and adult social care information supports your individual care. It also helps us to research, plan and improve health and care services in England.

There are very strict rules on how this data can and cannot be used, and you have clear data rights. We are committed to keeping patient information safe and will always be clear on how it is used.

You can choose whether or not your confidential patient information is used for research and planning.

If you do not wish your information to be used in this way please opt-out by visiting nhs.uk/your-nhs-data-matters or by calling 0300 303 5678. The practice is unable to record this for you.

NHS Organ Donor registration

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

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: blood.co.uk or call direct on 03001232323.

What happens to my information?

Pharmacy Nomination Optional

If you ticked 'Other pharmacy', please confirm your pharmacy address below Optional

Signature

confirm

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

Signature