New Patient Registration Form (Children/ Under 16): The Avenue Medical Centre

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: 20/09/2022

Patients Details (Summary)

Title *

Registration Type, Permanent or Temporary? *

Permanent Registration

Temporary Registration 3 Months

Temporary Registration 6 Months

Surname *

First name(s) *

Previous Surname

Birth Town *

Birth Country *

Date of Birth *

NHS number

Gender *

Male

Female

Address *

Postcode *

Main Telephone Number

Additional Telephone Number

Email Address

If you are new to the UK

Please provide the Practice with your Childs Immunisation record or copies of Immunisation Certificates (we can scasn these for you)

What date did you come to the UK (N/A if not applicable) *

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

Your previous address in UK (N/A if not applicable) *

Name of previous GP while at previous address

Address of that Doctor

Demographics

What is your ethnic group? (Choose one option that best describes your ethnic group or background) (optional)

What is your main spoken language? (optional)

What is the language you mainly read in? (example: English, French, Polish) *

What is your main religion? (optional)

Sex and Gender identity- which of the following best desrcibes you?

Is the gender you identify with the same as your sex registered at birth?

Marital Status

Next of Kin/ Parent or Guardian Information

1.Parent or Guardian: Name and Date of Birth

2. Parent or Guardian: name and date of birth

Looked After children

Are they a looked after child?

Yes No

Are they registered disabled

Yes No

If yes to above please provide details

Your Health

Height (optional)

Weight (optional)

Do you have any significant family history we should be aware of? Please list: (optional)

Summary Care Record: (www.nhscarerecords.nhs.uk)

This record will contain summary information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely. Your Summary Care Record will be available to authorised healthcare staff providing you with care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill away from home, healthcare staff treating you will have immediate access to important information about your health.

Do you consent to having a Summary Care Record?

Yes No

YOUR MEDICAL INFORMATION – SHARING YOUR DATA:

Under the General Data Protection Regulations (GDPR), we have a responsibility to keep your medical records confidential. We need your consent to share this with other authorised health professionals involved in your care or in planning your care. More information is available on the website or the number below. Please see the Privacy Notice on our website for more information on how your data is held and used by the practice. Your Data Matters: nhs.uk/your-nhs-data-matters Tel: 0300 303 5678 The NHS wants to make sure you and your family has the best care now and in the future. Your health and adult social care information supports your individual care. It also helps us to research, plan and improve health and care services in England. There are very strict rules on how this data can and cannot be used, and you have clear data rights. We are committed to keeping patient information safe and will always be clear on how it is used. You can choose whether or not your confidential patient information is used for research and planning. If you do not wish your information to be used in this way please opt-out by visiting the Website nhs.uk/your-nhs-data-matters or calling 0300 303 5678. The practice is unable to record this for you.

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New Patient Registration Form (Children/ Under 16): The Avenue Medical Centre

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