CHILDREN 0 TO 15 NEW PATIENT REGISTRATION FORM (GMS1) 2022

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. Your details will be held at the surgery for a limited period of time. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 08/08/2022

PATIENT DETAILS

TITLE

Surname *

First name(s) as on Official ID *

Any Middle Name *

Previous Surname/s

Birth Town *

Birth Country *

Date of Birth *

NHS number if known, this is required to trace your medical records.

Sex *

Male

Female

Other?

Address *

Postcode *

MOBILE PHONE NUMBER *

LANDLINE TELEPHONE NO *

Email Address *

ETHNICITY & RELIGION

Please tick one box that best describes your Ethnic group or background and Religion from the options below:

ACCESSIBLE INFORMATION STANDARD

The Accessible Information Standard aims to ensure that patients (or their carers) who have a disability or sensory loss receive information they can access and understand. For example in large print, braille or via email

Please fill in the questionnaire below, your responses will be added to your medical record for information.

Do you have any communication needs?

Yes No

If Yes, Please give details? *

Do you have any special communication requirements?

Yes No

If Yes please give details *

Do you need a format other than standard print?

Yes No

How would you like us to communicate with you *

Can you explain what support would be helpful when accessing the surgery? *

What is the best way to send you information? *

PLEASE HELP US TRACE YOUR PREVIOUS MEDICAL RECORDS BY PROVIDING THE FOLLOWING INFORMATION

Your previous address in UK

Name of previous GP practice while at that address

Address of previous GP practice

WERE YOU EVER REGISTERED WITH AN ARMED FORCES GP?

These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas

Regular

Reservist

Veteran

Family Member (Spouse, Civil Partner, Service Child)

Enlistment Date

Discharge date (if applicable)

Address before enlisting

Service or Personnel Number

IF YOU ARE FROM ABROAD

YOUR FIRST UK ADDRESS WHERE YOU REGISTERED WITH A GP

If previously resident in UK, date of leaving

Date you first came to live in UK

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 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.

Please tick one of the following boxes:

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 GHIC, or payment of the Immigration Health Charge ('the Surcharge'), when accompanied by a valid visa. I can provide documents to support this when requested

I do not know my chargeable status

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.

Are you a parent or guardian, filing out this form on behalf of a child under 16?

NAME OF PARENT/GUARDIAN *

RELATIONSHIP TO PATIENT?

Date *

NON-UK GLOBAL HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

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

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

By using your GHIC or PRC for NHS treatment costs your GHIC 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 GHIC, 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

Do you have a non-UK GHIC or PRC?

Yes No

If yes, please enter details from your GHIC 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 (e.g. 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 the practice staff.

I have an S1 form

Complete Registration

Would you like Electronic Prescribing (EPS) set up with your Chosen Pharmacy so that your prescription goes directly to your pharmacy? *

Yes No

If ‘Yes’, which Pharmacy would you like to collect your prescription from? *

SIGNATURE

Signature of patient

Signature on behalf of patient

Signed

Date *

CHILD HEALTH QUESTIONNAIRE

Please complete the following health questionnaire.

ONLINE SERVICES

At registration we offer all patients an Online Account that allows them to book appointments and request medication Online. Proxy Access allows Parent/Guardian to access and manage parts of the Patient's GP Online Services account. The Proxy is given their own Online Access Account

WOULD YOU LIKE A PROXY ACCOUNT FOR YOUR CHILD SO THAT YOU CAN BOOK APPOINTMENTS AND REQUESTS MEDICATIONS? *

If yes, complete the Access to Online Registration

PARENT/GUARDIAN DETAILS

NAME OF PARENT/GUARDIAN 1 *

DATE OF BIRTH OF PARENT/GUARDIAN 1 *

CONTACT DETAILS OF PARENT/GUARDIAN 1 (MOBILE/EMAIL) *

IS THIS PARENT/GUARDIAN 1 REGISTERED AT BARTON HOUSE *

Yes No

NAME OF PARENT/GUARDIAN 2 *

DATE OF BIRTH OF PARENT/GUARDIAN 2 *

CONTACT DETAILS OF PARENT/GUARDIAN 1 (MOBILE/EMAIL) *

IS THIS PARENT/GUARDIAN 1 REGISTERED AT BARTON HOUSE *

Yes No

NHS SUMMARY CARE RECORD WITH ADDITIONAL INFORMATION

If you are registered with a GP practice in England you will have a Summary Care Record (SCR), unless you have previously chosen not to have one. It includes important information about your health:

Medications you are taking
Allergies you suffer from
Any bad reactions to medicines

You may need to be treated by health and care professionals that do not know your medical history. Essential details about your healthcare can be difficult to remember, particularly when you are unwell or have complex care needs. Having an SCR means that when you need healthcare you can be helped to recall vital information.

SCRs can help the staff involved in your care make better and safer decisions about how best to treat you.

You can choose to have additional information included in your SCR, which can enhance the care you receive. This information includes:

Your illnesses and health problems
Operations and vaccinations you have had in the past
How you would like to be treated -such as where you would prefer to receive care
What support you might need
Who should be contacted for more information about you.

If you require any more information, please visit www.hscic.gov.uk/scr/patient phone HSCIC on 0300 303 5678 or speak to your GP Practice

If you would like this information adding to your Child's SCR, please complete below *

I wish my child to have a SCR with additional information (For practice use: code 9Ndn)

Name of Person completing this *

Capacity *

PARENT

LEGAL GURDIAN

LASTING POWER OF ATTORNEY FOR HEALTH AND WELFARE

ALLERGIES

Is the child allergic to any medication? If so which? *

CHILD IMMUNISATION RECORD

Please note for children under 5 who have had a previous GP we will need to copy the relevant immunisation entries in the child’s Red Book or if coming from aboard the equivalent Immunisations Book or Paperwork, please email these to the Practice: cahccg.registrations.bartonhouse@nhs.net

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. HIS IS TO CONFIRM YOU ARE REGISTERED WITH TEH PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YPUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNER IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

I consent to the practice collecting and storing my data from this form.

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CHILDREN 0 TO 15 NEW PATIENT REGISTRATION FORM (GMS1) 2022

Please tick one box that best describes your Ethnic group or background and Religion from the options below:

Further Information