Register - Child (Under 16) - Manor View Practice

New Patient Registration – Child (Under 16 Years Old)

Important Notice

In order to be fully registered with this practice, this form MUST be completed by the parent / guardian on behalf of the child. Please note that children under 16 will not be registered unless a parent / guardian is also registered at the practice.

A parent / guardian will need to provide one of the following documents to complete the registration process:

- the child’s birth certificate
- legal documents
- passport or other photo identification

This can be done by either uploading a clear photograph of on of the documents at the end of the registration form or by attending the practice in person.

Child's Personal Details

Please specify title

First name

Middle name

Last name

Known as

Previous last name (if applicable)

Date of birth

NHS number (providing this will speed up registration)

Gender

Male Female Intersex

Child's Background Information

Religion

Ethnicity

Do you speak English?

Yes No

Do you read English?

Yes No

What is your first language?

Please specify language

Do you require an interpreter?

Yes No

Have you ever been registered with Manor View Practice before?

Yes No

Are you registering for a temporary time?

Yes No

When are you likely to leave us?

School or Nursery Details

Name of school or nursery

Address of school or nursery

Child's Home Address

Home address

Post code

Town and country of birth

Child's Contact Details

Primary phone

Home phone

Mobile phone

Email address

Do you have any communication needs? E.g. large print or specific coloured paper.

Yes No

Preferred communication method

Telephone Text Email Post

Notification Consent

Do you consent to us contacting you by text?

Yes No

Do you consent to us contacting you by email?

Yes No

Child's Previous Details

Do you have a previous UK address?

Yes No

Previous home address

Previous post code

Have you previously been registered with another GP practice in the UK?

Yes No

Previous GP address

Previous GP post code

Are you registering with a GP practice for the first time in the UK?

Yes No

Date you came to the UK

First UK address

First UK post code

Are you returning from abroad?

Yes No

Date you left the UK

Date you returned to the UK

Parent / Guardian Details

1st Parent / Guardian Details

First name of parent / guardian

Last name of parent / guardian

Date of birth of parent / guardian

Relationship to child

Address of parent / guardian

Post code of parent / guardian

Mobile phone number of parent / guardian

Home phone number of parent / guardian

Are you the next of kin?

Yes No

Do you give us permission to discuss your medical records with the first parent / guardian?

Yes No

Do you want to add a 2nd parent / guardian's details?

Yes No

2nd Parent / Guardian Details

First name of parent / guardian

Last name of parent / guardian

Date of birth of parent / guardian

Relationship to child

Address of parent / guardian

Post code of parent / guardian

Mobile phone number of parent / guardian

Home phone number of parent / guardian

Are you the next of kin?

Yes No

Do you give us permission to discuss your medical records with the first parent / guardian?

Yes No

Child's Medical History

Sight and hearing adjustments can be made at the practice

How is your child's sight?

Good Poor Registered blind

How is your child's hearing?

Good Poor Partially deaf Registered deaf

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

Yes No

Please give details of any long-term illness, health problem or disability

Does your child Smoke?

Yes No

Is your child allergic to any medicine?

Yes No

Which medicines?

Does your child have any other allergies?

Yes No

Please give details of what you are allergic to, what happens and when you had your first reaction

Is your child currently taking any regular medications?

Yes No

Please give details of any current medications you are taking

Has your child had any serious illnesses or operations?

Yes No

Please give details of what serious illnesses and when

Do your child have contact with any of the following?

Has your child ever been under a Child Protection Plan?

Yes No

Brother/Sisters/Siblings (Please give details of Name and Date of Birth)

Immunisations

Important Notice

It is important that your child’s immunisations are kept up to date. A current copy of the immunisation history will help us to maintain their immunisation record.

Please either bring in your red book so that we can take a photocopy of this at reception or upload clear pictures of the immunisation history using the upload file links below.

Here is a list of the immunisations your child should have:

1st Diphtheria, Tetanus, Whooping Cough, Polio, Hib , rotavirus* (age 2 months)
2nd Diphtheria, Tetanus, Whooping Cough, Polio, Hib, rotavirus* (age 3 months)
3rd Diphtheria, Tetanus, Whooping Cough, Polio, Hib (age 4 months)
1st Pneumococcal (aged 2 months)
2nd Pneumococcal (aged 4 months)
1st Meningitis C (aged 3 months)
Hib/ Meningitis C
1st Measles, Mumps, Rubella (MMR) (aged 12-13 months)
Booster Pneumococcal
Booster Diphtheria, Tetanus, Whooping Cough, Polio (aged 3 years 4 months)
Booster Measles, Mumps, Rubella (MMR)

Do you want to upload pictures of your child’s immunisations from their red book?

Yes No

Immunisations upload 1

Immunisations upload 2

Immunisations upload 3

Electronic Prescribing

The Electronic Prescription Service (EPS) is an NHS service that sends electronic prescriptions from GP practices to pharmacies allowing you to choose where you get your medications or appliances from.

Would you like to nominate a pharmacy for electronic prescribing?

Yes No

Name and address of nominated pharmacy

Declaration

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 have access to your records are 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.

My Data Matters

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 by 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

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.

Identification Upload

To complete your child's registration process, we require one of the following documents:

birth certificate

legal documents

passport or other photo identification

To speed up the registration process you can upload a clear picture of one these documents using the file upload function below, or you can bring this documentation to the practice in person.

File Upload

Consent

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

Yes No

I confirm that I have uploaded or will bring into the practice one of the following documents: child's passport or other photo identification, child's birth certificate or legal documents.

Yes No

I confirm that I have uploaded or will bring into the practice the child's red book detailing their immunisations.

Yes No

Signature of parent / guardian (print name)

Date