Personal Details

    Title

    Gender

    Given Name

    Family Name

    Previous Surnames (If any)

    Date of birth

    NHS Number

    Town and city of Birth

    House Name/Flat Number

    Street/Road name

    Town/City

    Post Code

    Home Phone

    Email


    Help us tract your medical records

    Your previous address in the UK

    Your previous address in the UK

    Address of you previous GP

    If you are from abroad

    Your first UK address where registered with a GP

    If previous resident in the UK, date of leaving

    Date you first came to the UK

    Were you ever registered with Armed Forces GP

    Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas:

    Address before enlisting

    Post Code

    Service or Personnel number

    Enlistment date

    Discharge date (if applicable)

    Footnote: These options are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority charities services

    If you need your doctor to dispense medicines and appliances*

    *Note: Not all doctors are authorised to dispense medicines



    NHS Organ Donor registrations

    NHS Organ Donor Donation
    I want to register my details on the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death.

    NHS Blood Donor Registration

    NHS Blood Donor Registration
    I would like to join the NHS Blood Donor register as someone who may be contacted and would be prepared to donate blood.


    Registration Health Questionnaire – Children 0-16

    We may not receive your child’s records for some time so please would you help us by filling out this form? It is really important that we know if they have had any illnesses, or are on treatment/ medication. If you are not sure of the answer to anything, just put “Don’t know”.

    Surname

    Forename(s)

    Preferred calling name

    Date of birth

    Gender

    Mobile number/Parent's mobile

    Email/Parent's email:

    Country of birth

    Main language

    Interpreter required

    0-5 years old only

    Were there any problems at birth or during the pregnancy?

    If yes please give details

    The only other parts of this form that must be completed for this age group are the immunisation and ethnicity sections, but you may complete other sections if you wish.

    Child questionnaire continued

    Do you have any concerns about your child you would like to discuss at the moment?

    If yes, please give details, or ask Reception for an appointment to be made

    Please give details of any serious illnesses / operations / stays in hospital, with approximate dates

    Any other inherited condition

    Is your child taking any regular medication?

    If yes, please state what the treatment is for, and name and dose of drug if known: (or you can ask the previous surgery for a print out of your child’s medication)

    Does he/she have any allergies to medicines, pollen, dust, animals, or any foods?

    If yes, please give details and state if the child has
    an Epipen

    Has / does a close relative (parent, brother, sister, uncle, aunt) ever suffered / suffer from asthma?

    If yes, which relative?

    Child's weight

    Child's height

    Health Visitor Clinics
    Our Health Visitors run a drop in clinic on Thursdays at Thurleigh Road from 2pm-3.30pm. Letters are sent out to parents by the Health Visitors inviting them to book an appointment elsewhere for the one year review.

    15-16 years old only

    Do you smoke?

    If yes, how many cigarettes a day on average?

    Have you ever smoked?

    If yes how much did you smoke and when did you give up?


    Child Immunisations

    We need to have an up-to-date record of your child’s immunisations.
    Please bring to the surgery

    • a print out of their immunisation history from their previous practice

    OR

    • your child’s RED BOOK

    We need to have an up-to-date record of your child’s immunisations history.

    Please complete the details of the date and type of immunisation(s) received:


    Children immunised outside the UK:

    Immunisation schedules differ from country to country, but vaccines given are mostly the same – please bring any immunisation records you may have with you when you register your child.

    Please complete the details of the date and type of immunisation(s) received:


    If your child needs any immunisations, please make an appointment with a Practice Nurse.

    If you have any questions about childhood immunisations, please make an appointment to discuss them with a doctor or Practice Nurse – or ask the Health Visitor at the drop in Baby Clinic.


    Immunisation Consent

    Please note that consent is required from the parent/guardian each time a child has an immunisation. If you are accompanying the child, consent can be given verbally at the appointment.

    Unless you accompany your child for their injections, you must send in a handwritten letter with the accompanying adult, or we will be unable to give the child their immunisations.


    Ethnic Group
    We are being asked by the Department of Health to record the ethnic group of all our patients, as government wants to make sure there is no discrimination against any ethnic group (Race Relations Amendment Act 2000).
    You do not have to tell us your ethnic group if you do not want to – just tick the “Not stated” box.

    All information given in this form will be treated in the strictest confidence


    Summary Care Record

    If you are registered with a GP practice in England, you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past. Having a Summary Care Record can help by providing healthcare staff treating you with vital information from your health record. You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. Your options are outlined below; (please indicate your choice).


    Accessible Information Standard/h4>

    Does your child have any special communication requirements/require specific communication support?

    If other please state here:

    What is the best way to send you information?

    If other please state here:

    Do you need the assistance of a Communication Professional?

    If other please state here:

    Identification

    Please upload proof of identification of the Child that that application is being made for. This can include passport or ID card so as we can verify their identity.

    (File types accepted .png, .jpg and .pdf. Maximum file size 5mb)

    Confirmation and signature

    Print name of signatory: