Child Registration Form Links Medical Practice

Surname *

First name(s) *

Previous Surname

Date of Birth *

Sex *

Female

Male

Telephone *

Mobile *

Email *

Home address *

If you live in a flat, please give flat number, letter or position (e.g. ground floor left). Otherwise, enter N/A *

Postcode *

First registration with a GP in the UK? *

Yes No

Will you be in the area for more than 3 months? - If 'no' then ask for form GMSTRF001" *

Yes No

NHS number (can be found on your current medical card)

Community Health Index - CHI (can be found on your current medical card)

Town of birth (can be found on your birth certificate) *

Country of birth (can be found on your birth certificate) *

Reg. district of birth (can be found on your birth certificate)

Mother's maiden name (can be found on your birth certificate) *

Other Household Members

Please help us to trace your medical records by providing the following information:

If you are from abroad

What medications do you use regularly (please give details - name of medication, dose, frequency). If none, please enter 'none' or 'N/A' IMPORTANT - PLEASE NOTE: We may only be able to register you once we have clear notification of your repeat medication - please make sure that you have a least one months supply of your medication and you have provided us a printed prescription copy of your repeat medication(s). *

Immunisations

Please enter dates given for the following immunisations

8 weeks old - Diptheria, tetanus, pertussis(whooping cough), polio, Haemophilus influenzae type b (Hib) and hepatitis B (HepB)

12 weeks old - Diptheria, tetanus, whooping cough, polio, Hib and HepB, Pneumococcal disease, Rotavirus

16 weeks old - Diptheria, tetanus, whooping cough, polio, Hib and HepB, Meningitis B (MenB)

Between 12 and 13 months old - Hib and meningococcal group C, Pneumococcal disease, Measles, mumps and rubella (German measles), Meningitis B (MenB)

Every year from age 2 until the end of primary school - Influenza (flu) Please enter all dates

3 years 4 months old - Diptheria, tetanus, whooping cough and polio, Measles, mumps and rubella (german measles)

11 to 13 years old - hpv (human papillomavirus)

around 14 years old - tetanus, diptheria and polio, meningococcal groups acwy

Other immunisations e.g. (BCG at birth

Voluntary consent to organ donation

I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death. Your consent to organ donation will be shared with NHS Blood and Transplant together with the information you have provided in Section 1 including your name, gender, date of birth address and CHI number. For more information on being an organ donor or privacy, please ask for the leaflet on joining the NHS Organ Donor Register or visit http://www.organdonation.nhs.uk.

Information Sharing

Patient Declaration

I declare that the information I have given on this form is correct and complete. I understand that, if it is not, appropriate action may be taken. To enable NHS National Services Scotland to confirm my eligibility to lawfully register with a GP and for the purposes of prevention, detection, and investigation of crime, relevant information from this form will be disclosed to the NHS Business Services Authority, NHS National Services Scotland, the Home Office, Identity and Passport Service, HM Revenue and Customs, the General Register Office and Local Authorities.

For Practice Use

GP Reference Number

GP Name

Practice Code

Mileage (road, water, footpath

Identification seen - do not take or retain photocopies

Birth Certificate

Student ID Card

Driving Licence

Passport or HC2 Certificate

Home Office App. Reg. Card

Other - specify

Receptionist Initials

I accept this patient onto the practice list and declare that, to the best of my knowledge, this information is correct. I acknowledge that the details may be authenticated from appropriate records, and that payments generated from this patient registration will be subject to Payment Verification.

Yes No

Authorised Practice Signature

Date Signed

Official Use Only

How we use your information

The information you have provided will be used by the GP Practice to carry out its various functions and services including scheduling appointments, ordering tests, hospital referrals and sending correspondence. Your information, including your name, gender, date of birth and address, will be passed to NHS National Services Scotland where it will be held on the Community Health Index (CHI). This information is used to register you with the GP Practice, transfer your medical records between GP practices in the UK, make payments to GP Practices for medical services provided, and to process and issue medical cards, medical exemption certificates and entitlement cards. NHS National Services Scotland shares information about you within NHSScotland to assist in the provision and improvement of NHS services and the health of the public. When we do this, we make sure that the information which identifies you as a person and your health information are separated or anonymised. Health condition and treatment information which could identify you will not be used for research purposes by the NHS unless you have consented to this. For more information on how NHS National Services Scotland uses your personal information visit http://www.nhsnss.org. If you have any queries or concerns about how your personal information is used by the NHS please ask for the leaflet ‘Confidentiality – it’s your right’, visit the Health Rights Information Scotland website at http://www.hris.org.uk or ask your GP surgery. NHS National Services Scotland is the common name of the Common Services Agency for the Scottish Health Service.

Privacy and security

Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of registration. Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.

Child Registration Form Links Medical Practice

Further Information