New Baby Registration Form

Title

Master

Miss

Other

NHS Number

Date of birth *

Place of birth *

Family name / surname *

Given names / first names *

Home address of child

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

Relationship to child

Surname *

Previous surname

First name(s) *

Date of birth *

Birth country *

Occupation

Marital status

Single

Co-habiting

Married

Separated

Divorced

Widowed

NHS number

Home address if different to child's

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

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

Any other adults who reside in your home

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

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 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.

Further Information

Cookies on the Sorrel Bank Medical Practice website

NEW BABY REGISTRATION FORM

Further Information

Connect With Us