Child Registration Form (Under 16) - The Croft Medical Centre

Thank you for applying to join Croft Medical Centre We would like to gather some information about your child and ask that you fill in the following questionnaire; you don’t have to supply answers to all of the questions but what you do fill in will help us give the best possible care.

Please supply the child’s birth certificate or a form of Identification with the completed form, a photographic form of ID (such as passport) and proof of your home address (such as a recent bank statement or document relating to your new home).

Croft Child GMS1

Step 1 of 2

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Please Upload any relevant documents

Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 10 MB, Max. files: 5.

(Proof of Identity, Proof of Address, Birth Certificate etc)

Child Details

Title

Full Name

First Last

Previous Surname Optional

(If applicable)

Gender

Date of Birth

Day

Month

Year

NHS Number

(If unknown, please enter “NA”)

Town and Country of Birth

Current Address

Street Address Address Line 2 City Postcode

(include Postcode)

Has the child lived at any previous addresses?

Yes

Previous Address

Street Address Address Line 2 City Postcode

(Include Postcode)

Mobile Number

Home Contact Number Optional

Enter Email Confirm Email

Please specify your preferred methods of contact

Mobile

Home Number

(Tick all that apply)

Is the child currently attending school?

Yes

Name of the school the child is registered with

Address of the school the child is registered with

Street Address Address Line 2 City Postcode

Is the child a looked after child?

Yes

A child who is being looked after by their local authority is known as a child in care. They might be living: with foster parents, at home with their parents under the supervision of social services or in residential children’s homes.

Please help us trace your child's medical records by providing the following information:

Has the child previously been registered with an NHS GP in UK?

Yes

Name of Previous GP

Address of Previous GP

Street Address Address Line 2 City Postcode

Your first UK address

Street Address Address Line 2 City Postcode

Further Details

I would describe the child’s ethnic group as…

If "other" please specify the child's ethnic group

Child's Main Spoken Language

(E.g. English)

Is the child a dependant of a current serving member of British Armed Forces?

Yes

Main Spoken Language Optional

(e.g. English)

Next of Kin / Emergency Contact

Is the contact named below authorised to discuss the child’s medical record with us?

Yes

Name of Next of Kin / Emergency Contact

First Last

Contact number for Next of Kin / Emergency Contact

Relationship to Child

Does the child's next of kin / emergency contact live at a separate address?

Yes

Address of Next of Kin / Emergency Contact

Street Address Address Line 2 City Postcode

Data Sharing

Summary Care Record (SCR)

Your SCR is an electronic summary of key medical information taken from your GP medical record.

If you need healthcare away from your usual doctor’s surgery, your enhanced SCR will provide those looking after you with key information to help them give you better and quicker care.

For more information visit: http://systems.digital.nhs.uk/scr

SCR Choice

I wish for the child to have an enhanced SCR with core and additional information (recommended)

I wish to opt-out of the SCR on the child’s behalf

Medical Interoperability Gateway (MIG)

The MIG enables secure sharing of relevant medical information from your GP record with other healthcare professionals who are providing you with direct care, even if they are not using the same electronic records system.

At point of care you will be asked if you consent to the care service seeing essential elements of your record.

More information can be found by visiting: http://www.healthcaregateway.co.uk/products

MIG Declaration

I wish to opt-out of the MIG data sharing Optional

Risk Stratification Preferences

Risk stratification is the process of identifying the relative risk of patients in a population by analysing their medical history.

It’s a key enabler for improving the quality of care delivered by the NHS.

Croft Medical Centre is taking part in the Risk Stratification programme and will be uploading patient identifiable data for analysis; patient identifiable information will only be viewable at GP practice level.

Any NHS organisation external to the practice using risk stratification will only see anonymised data.

Risk Stratification Declaration

I wish to opt-out of Risk Stratification Optional

Enhanced Data Sharing Module (EDSM)

Croft Medical Centre use a clinical computer system called SystmOne to record your medical information.

With your consent, you can allow your full GP record to be shared with other healthcare services that are providing care for you and who also use SystmOne.

These other services will always ask consent to view your record.

Enhanced Data Sharing Module Declaration

I wish to opt-out of the Enhanced Data Sharing Module Optional

Carers Information

A carer is a friend or family member who gives their time to support a person in their home, to an extent that the person could not remain at home if this care was not being provided.

A carer can receive Carers Allowance, but not a wage and the care they are giving will significantly affect their own life.

Is the child looked after or supported by someone who they couldn’t manage without?

Yes

Carer's Name

First Last

Carer's Contact Number

Do you consent for the carer to be informed about the child’s medical care?

Yes

Does the child look after or support someone who couldn’t manage without them?

Yes

If yes, do they look after someone who is a patient of Croft Medical Centre?

Yes

Don’t know

Name of the person receiving care

First Last

Is the person receiving care a…

Relative

Friend

Neighbour

Please detail any contact that the child has with other professionals such as health visitors and social workers Optional

Medical Details

In order to continue to receive repeat medications you’ll need to make a new patient health check appointment for the child and bring in their last repeat prescription. (Please note, certain medications will require an appointment with the GP before they can be prescribed, please allow plenty of time to organise repeats)

Please provide us with your child’s repeat medication list found on the right hand side or a printed prescription.

Is the child allergic to any medicines?

Yes

Please specify

List other allergies / intolerances Optional

(i.e. nuts, gluten, pollen, animal hair or certain foods. Please type “none” if the child has no other allergies that you know of)

Has the child ever had any of the following conditions?

Epilepsy Optional

Mental Illness Optional

High Blood Pressure Optional

Diabetes Optional

Heart Attack / Angina Optional

Asthma Optional

Stroke / Mini-stroke (TIA) Optional

COPD (or Emphysema) Optional

Cancer Optional

Osteoporosis / Bone fractures Optional

Rheumatoid Arthritis Optional

Peripheral vascular disease Optional

(Please tick all that apply; if none of the above, please leave empty)

Please provide details for each condition checked

(Year diagnosed, Severity, Treatment)

Does the child have any disabilities, illnesses or accessibility needs?

Yes Optional

No Optional

(I.e. needing to be seen in ground floor consulting rooms or use of a specific communication device such as a hearing aid?)

Please Specify

The Accessible Information Standard (AIS)

Please use the space below to tell us about any specific communication needs your child may have. (I.e. needing information in large print or deafblind telephone contact)

For further information please visit https://www.england.nhs.uk/ourwork/accessibleinfo/

Please specify your child's communication needs Optional

(If applicable)

Does the child have a family history of any of the following?

High Blood Pressure Optional

DVT / Pulmonary Embolism Optional

Ischaemic Heart Disease (Diagnosed aged >60 yrs) Optional

Ischaemic Heart Disease (Diagnosed aged <60 yrs) Optional

Breast Cancer Optional

Any Cancer (Specify type below) Optional

Raised Cholesterol Optional

Thyroid disorder Optional

Stroke / CVA Optional

Epilepsy Optional

Asthma Optional

Osteoporosis Optional

(Please tick all that apply; if none of the above, please leave empty)

Please provide details for each condition checked

(Family Member effected, Year diagnosed)

Does the child smoke?

Yes

Is the child an ex-smoker?

Yes

When did they quit?

How much did the child used smoke a day?

If yes, what does the child primarily smoke?

Cigarettes

Cigar

Pipe

Vape

How much does the child smoke a day?

Would you like advice on quitting smoking?

Yes

Does your child exercise regularly?

Yes

Please specify what exercise they take and how often

Prescriptions

Would you like any 3rd parties to be able to collection prescriptions for the child?

Yes

In accordance with the Data Protection Act, the practice needs consent if you are happy for a 3rd party to collect prescriptions, test results and other medical information on your child’s behalf.

Please complete this section if you would like to register a 3rd party.

Name of 3rd Party

First Last

Consent Declaration

I give consent for the aforementioned 3rd party to collect prescriptions on my child’s behalf (Please note that we are unable to hand out prescriptions to anyone under the age of 15)

I give consent for the aforementioned 3rd party to obtain test results / medical information / appointment information on my child’s behalf

(Please tick all that apply, it is YOUR RESPONSIBILITY to advise us of any changes to these instructions)

Electronic Signature (Type your full name here)

(Type your full name)

Electronic Prescription Service (EPS)

EPS enables prescribers – such as GPs and practice nurses – to send prescriptions electronically to a dispenser (such as a pharmacy) of the patient’s choice.

This makes the prescribing and dispensing process more efficient and convenient for patients and staff.

If you have already nominated a pharmacy, please tell us which pharmacy you have chosen.

For further information about this service, please talk to your pharmacist of choice.

Additional Important Information

Please record any additional information about your child that you think is important for us to know Optional

NHS Organ Donor registration

I want to register my child’s details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after their death. Please tick the boxes that apply.

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death

Any of my organs and tissue

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

None of the above

(Check all that apply) For more information, please visit the website www.uktransplant.org.uk or call 0300 123 23 23

Signatures

Signed

(Legal Guardian’s Full Name)

Today's Date

Day

Month

Year

Phone Optional

This field is for validation purposes and should be left unchanged.