UNDER 18s NEW PATIENT REGISTRATION FORM including GMS1 V2

Fields marked "REQUIRED" are compulsory.. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 16/12/2022

SUPPLEMENTARY QUESTIONS / 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 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 resident, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your 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.

PLEASE TICK ONE OF THE FOLLOWING BOXES

I do not know my chargeable status

I understand that I may need to pay for NHS treatment outside of the GP practice

I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. this includes for example, an EHIC, or payment of the Immigration Health Charge ("the Surcharge"), when accompanied by a valid visa. I can provide documents to support this when requested

Details of child registering

Title

Master

Miss

Other

Mrs

NHS Number

Date of birth *

Place of Birth *

Family name / surname *

Given names / first names *

Home address of child

House name / flat number

House number and street *

Town *

County *

Postcode *

About the applicant

Current Contact Details for the child

Home telephone number *

Mobile telephone number *

Consent to SMS / text contact

Yes No

Email address

Consent to email contact

Yes No

Person with parental responsibility

NB. Parent or guardian must also be registered with the practice

Title *

Relationship to child *

Surname *

Previous surname

First name(s) *

Date of birth *

Birth town *

Birth country *

Occupation

Marital status

Single

Co-habiting

Married

Separated

Divorced

Widowed

NHS number

Home address if different to child's

House name / Flat number

House number and street

Town

City

County

Postcode

Current Contact Details of person with parental responsibility

Home telephone number *

Work telephone number

Mobile telephone number *

Consent to SMS / text messaging

Yes No

Email address

Consent to email contact

Yes No

Legal orders

Is the child subject to any legal orders

Yes No

Please help us trace the previous medical records of the child by providing the following

Applicants previous address in the UK *

Name of previous GP whilst at previous address *

Address of that Doctor *

School

Name of school / Further education establishment *

Caring Responsibilities of the child

Caring for a child

Do you have any caring responsibilities for children under the age of 18

Yes No

Child's name

Child's date of birth

Child's address if different from your own

What is the relationship to you

What is their contact telephone number

Child's name

Child's date of birth

Child's address if different from your own

What is the relationship to you

What is their contact telephone number

Child's name

Child's date of birth

Child's address if different from your own

What is the relationship to you

What is their contact telephone number

Caring Responsablity of the child

Caring for an adult

Do you have any caring responsibilities for anyone over the age of 18 who is dependent on you for some or all of the time

Yes No

Adults name

Adults date of birth

Adults address if different from your own

What is their relationship to you

What is their contact number

Is this person a patient of Sorrel Bank Medical Practice

Yes No

Do you (the child) have a carer

If YES, what is the name of your carer

What is their relationship to you

What is their contact telephone number

Any other adults who reside in your home

Child's Medical History

Child's Current Medications

Please list all of your current medications and the health condition they are taken for

Does the child have any drug allergies?

Yes No

If the child does have a drug allergy, please llist the medication

Chld's Immunisation History

Please give the date of your immunisations

BCG

1st Diphtheria / Tetanus / Pertussis / Polio / Hib

1st Pneumococcal

1st Rotavirus

2nd Diphtheria / Tetanus / Pertussis / Hib

1st Meningitis C

2nd Rotavirus

3rd Diphtheria / tetanus / Pertussis / Hib

2nd Pneumococcal

Hib / Meningitis C

MMR 1

Pneumococcal booster

Diphtheria / Tetanus / Polio / Pertussis booster

MMR 2

HPV

Diphtheria / Tetanus / Polio booster

Meningitis C booster

Other

Childhood Illness

Child's Lifestyle History

Online Services Registration

Would you like to register for online services

Yes No

Which services would you like to register for

Appointments

Repeat prescriptions

Medical History

Summary Care Record Sharing

Do you object to your summary care record being available when you access NHS care outside of your GP practice? (for example NHS Out of Hours or Accident & Emergency) *

I agree to my summary care record being made available when I acess NHS care outside of my GP practice

I object to my summary care record being made available when I access NHS care outside of my GP practice

Parent / Guardian / Patients Declaration

By signing below you are declaring that the information contained within this patient registration form is accurate to the best of your knowledge. Any suspected fraudulent information will be reported to the relevant authorities.

If you are registering a child under 5

I wish the child above to be registered with the named doctor for Child health Surveillance

Today's date

Signature of registrant, if registering on behalf of yourself

Signature of authorised person, if registering on behalf of someone else i.e a baby

Relationship to person registering

NON-UK European Health Insurance Card (EHIC), Provisional Replacement Cerificate (PRC) details and S1 forms

Complete this section if the applicant lives in another EEA country, or has 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 he cost of any treatment received outside the GP practice, including at hospital).

Do you have a non-UK EHIC or PRC?

Yes No

If yes, please enter the details from your EHIC or PRC below:

Country code

Name

Given Names

Date of birth

Personal identification number

Identification number of the institution

Identification number of the card

Expiry date

PRC validity period

A) From

B) To

Please tick if you have an S1 (eg. you are retiring to the UK or you have been posted here by your employer for work or you live in the Uk but work in another EEA Member State). Please give your S1 form to hte practice staff

I have an S1 form

How will your EHIC / PRC / S1 data be used?

By suing 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.

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UNDER 18s NEW PATIENT REGISTRATION FORM including GMS1 V2

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