GMS1 and New Patient Child Registration Form (0-15 years old)

The information you provide is confidential and will be kept confidential.

Please help us trace previous medical records by providing the following information

Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision

All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23

Please note: we may contact you by text message or email. Only include these details if you are happy to be contacted this way.

Is there family history of the following ?

When registering a child under 5 years of age, you will need to provide us with a record of the child's previous immunisations from the child's red book (Personal Child Health Record). Immunisation records are very important for the well being of your child. Collecting this information will ensure that we have an up to date record, including when the next vaccinations are due.

What is the child's Main Spoken Language? This is the language spoken at home or family environment, regardless of how well the child speaks English.

This Practice is set up for electronic prescription service. This means that for most patients we can send the prescription to their chosen chemist directly saving patients having to come down to the practice to collect their prescription. If you would like to use this service for the child's prescriptions, please state your nominated pharmacy below:

Patient Text Messaging Service now includes appointment reminders, test results, health promotion, invitations to take part in research studies (voluntary) and updates. Consent to use this service is required. It is important that you notify the Practice at any time when you change either the registered mobile number or email address. If you wish to withdraw this consent at any time in the future, you are free to do so. Please contact the Practice should this be the case.

The NHS data sharing initiatives that the Practice is involved in are the Summary Care Record (SCR) and Joined-up Health and Care records. Please see details below.

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 gives health and care professionals, away from your usual GP practice, access to information to provide you with safer care, reduce the risk of prescribing errors and improve your patient experience. 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. The information shared will solely be used for the benefit of your care. Your options are outlined below; please indicate your choice. You are free to change your decision at any time by informing the Practice. For further information on Summary Care Record, please refer to http://digital.nhs.uk/scr/patients

Health and care organisations across North Central London are working together to use digital technology to improve health and care across Barnet, Camden, Enfield, Haringey and Islington. Having joined-up health and care records means that the health and care professionals involved in your care can see your information and make quicker and safer decisions with you. Only those who need to see your information to support your health and social care will have access to personal information. This could include GPs, social workers, hospital clinicians, community health practitioners, mental health staff and other authorised members of the care team. Each person will only be able to view information relevant to their job. If you are happy for your information to be part of this joined up health and care record, then you don’t need to do anything. However, if you don’t want to be included, you need to take action. Please refer to the ‘Joining up Health Care Records’ leaflet for further information.

Patient data from GP medical records kept by GP practices in England is used every day to improve health, care and services through planning and research, helping to find better treatments and improve patient care. The NHS is introducing an improved way to share this information - called the General Practice Data for Planning and Research data collection. NHS Digital has been directed by the Secretary of State for Health and Social Care to collect and analyse data from GP practices for health and social care purposes including policy, planning, commissioning, public health and research purposes. If you DO NOT want your identifiable patient data (which will be pseudonymised) to be shared for purposes except for your own care, you can opt-out by registering a Type 1 Opt-out with the practce or a National Data Opt-Out, with NHS Digital, or both. These opt-outs are different and they are explained in more detail on our website.

e.g. web search, NHS choices, word of mouth?

If you are filling out this form on behalf of the person listed on page 1, please ensure that you fill out your details below:

PATIENT DECLARATION FOR ALL PATIENTS WHO ARE NOT ORDINARILY RESIDENT IN THE UK. Anybody in England can register with a GP practice and receive free medical care from that practice. However, if you are not 'ordinarily resident' in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of 'indefinite leave to remain' in the UK. Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges. More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice. You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment. The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

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. If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC)/S1, you may be billed for the cost of any treatment received outside the GP practice, including at hospital).

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.