CHILD - NEW REGISTRATION FORM

WELCOME TO LYNDHURST SURGERY ADULTS ONLY FORM – AGED 17 + TO REGISTER WITH THIS PRACTICE AT LEAST TWO TYPES OF IDENTIFICATION ARE REQUIRED. AT LEAST ONE MUST HAVE YOUR CURRENT ADDRESS, FOR EXAMPLE: BIRTH/MARRIAGE CERTIFICATE, MEDICAL CARD, DRIVING LICENCE, PASSPORT, PAID UTILITY BILL, BANK/BUILDING SOCIETY CARD OR STATEMENT, NATIONAL INSURANCE NUMBER CARD, PAYSLIP, LETTER FROM BENEFITS AGENCY/BENEFIT BOOK/SIGNING-ON CARD OR PAPERS FROM THE HOME OFFICE.

Last Updated: 16/09/2020

PLEASE BRING THE CHILD’S RED BOOK WITH YOU SO WE CAN TAKE A COPY OF THEIR IMMUNISATION RECORD.

CONFIDENTIAL MEDICAL REGISTRATION FORM (CHILDREN 0 – 16 INC)












CARERS DETAILS




















REQUIRED INFORMATION:










PRIVATE FOSTERING IS AN ARRANGEMENT WHEREBY A CHILD UNDER THE AGE OF 16 (OR 18 IF THE CHILD HAS A DISABILITY) (S.66 CHILDREN ACT 1989) IS PLACED FOR 28 DAYS OR MORE IN THE CARE OF SOMEONE WHO IS NOT THE CHILD’S PARENT(S) OR A ‘CONNECTED PERSON’. PRIVATE FOSTER CARERS CAN BE FROM THE EXTENDED FAMILY, E.G. A COUSIN OR A GREAT AUNT, BUT CANNOT BE A RELATIVE AS DEFINED UNDER THE CHILDREN ACT 1989, SECTION 105:‘A RELATIVE UNDER THE CHILDREN ACT 1989 IS DEFINED AS A ‘GRANDPARENT, BROTHER, SISTER, UNCLE OR AUNT (WHETHER FULL BLOOD OR HALF BLOOD OR BY MARRIAGE OR CIVIL PARTNERSHIP) OR STEP-PARENT’.

PLEASE HELP US TRACE THE CHILD’S PREVIOUS MEDICAL RECORDS BY PROVIDING THE FOLLOWING INFORMATION:




IF YOU ARE FROM ABROAD:



IF REGISTERING A CHILD UNDER 5:


IF YOU NEED YOUR DOCTOR TO DISPENSE MEDICINES AND APPLIANCES:

FOR DISPENSING PRACTICES ONLY:


CHILD’S PERSONAL MEDICAL HISTORY:


HAS YOUR CHILD EVER SUFFERED FROM ANY IMPORTANT MEDICAL ILLNESS, OPERATION OR ADMISSION TO HOSPITAL? IF SO PLEASE ENTER DETAILS BELOW (IF EXTRA SPACE IS REQUIRED PLEASE USE BOX AT END OF FORM):







FAMILY MEDICAL HISTORY:












CHILD’S IMMUNISATIONS:

PLEASE PROVIDE DETAILS OF YOUR CHILD’S IMMUNISATIONS WITH DATES IF POSSIBLE (UNDER 5’S). IF POSSIBLE PLEASE GIVE YOUR RED BOOK TO RECEPTION TO PHOTOCOPY:














CHILD’S LIST OF CURRENT MEDICATION:











CHILD’S ALLERGIES:

PLEASE LIST ANY ALLERGIES THE CHILD HAS TO ANY DRUGS/MEDICATIONS OR IF KNOWN EGG ALLERGY OR PEANUT ALLERGY:










CHILD’S RELIGION:



CHILD’S LANGUAGE:



DATA SHARING CONSENT CHOICES:

TO MAINTAIN CONTINUITY OF CLINICAL CARE, WE UPLOAD CERTAIN MEDICAL INFORMATION SO THAT IT IS AVAILABLE TO OTHER HEALTHCARE ORGANISATIONS (EG EMERGENCY DEPARTMENTS). PLEASE READ THE ACCOMPANYING LEAFLET WHICH DETAILS WHAT PART OF YOUR RECORD IS EXTRACTED AND HOW IT IS USED TO HELP OTHER NHS ORGANISATIONS. IF YOU WISH TO OPT OUT PLEASE COMPLETE THE FORM FOUND WITH THIS LEAFLET. WHERE YOU HAVE PROVIDED INFORMATION ON HOW TO CONTACT YOU, CAN YOU CONFIRM YOU ARE HAPPY FOR [INSERT NAME OF PRACTICE] TO CONTACT YOU BY THE FOLLOWING:



SIGNATURES:

I CONFIRM THAT THE INFORMATION THAT HAS BEEN PROVIDED IS TRUE TO THE BEST OF MY KNOWLEDGE.








PATIENT DECLARATION for all patients who are not ordinarily resident in the UK












COMPLETE THIS SECTION IF YOU LIVE IN ANOTHER EEA COUNTRY, OR HAVE MOVED TO THE UK TO STUDY OR RETIRE, OR IF YOU LIVE IN THE UK BUT WORK IN ANOTHER EEA MEMBER STATE. DO NOT COMPLETE THIS SECTION IF YOU HAVE AN EHIC ISSUED BY THE UK

NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS














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