Under 16 Registration Questionnaire

Title

Surname

First names

Any previous surnames (if applicable)

Date of Birth

Are you:

Town & Country of birth

NHS Number

Home address

Postcode

Home telephone number

Work telephone number

Mobile Number (if you have one)

Email address

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

Previous address in the UK (if applicable):

Postcode

Name of previous doctor

Address of previous doctor

If your child is from abroad

First UK address where your child was registered with a GP if your child was previously living abroad

Postcode

If previously a resident in the UK, date of leaving

Date your child first came to live in the UK (if applicable)

Armed Forces

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

If you need your doctor to dispense medicines and appliances*

* Not all doctors are authorised to dispense medicines

Do you live more than 1.6km in a straight line from the nearest chemist

Would you have serious difficulty in getting them from a chemist

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 select one of the following statements

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

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.

NON-UK EUROPEAN 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 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 the cost of any treatment received outside of the GP practice, including at a hospital.

Do you have a non-UK EHIC or PRC?

If yes, please enter 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 from

PRC validity period to

Do 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).

How will your EHIC/PRC/S1 data be used? By using 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.

Additional Information

Main Spoken Language (eg English, British Sign Language (BSL)

If you need help with reading/writing please indicate what support you require

Looked after child

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 pr in a residential children’s home

If you are applying on behalf of a child who is in foster care/residential care/kinship care/or who is not your child. Please select appropriate option

The child is in Foster Care The child is in residential care

The child is in Kinship care (looked after by a relative eg grandparent)

Name of Legal Parent or Guardian

The above person can consent for the medical treatment of the child

Other named person can consent for the medical treatment for the child

Please specify name

If you are registering a child under 5

I wish the child above to be registered for Child Health Surveillance

Carer’s Information

A carer is a friend/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 the care was not being provided.

Do you have a carer

If yes what is their name(s) and contact number (s)

Do you consent to the carer being informed about the child’s medical care

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

If yes, do they look after someone who is a patient at Springfields Medical Centre

If yes, what is their name

Are they a friend/relative/neighbour

Please detail any contact that the child has with other professionals such as Health Visitors/Social Worker

Next of Kin/Emergency Contact

Are the contacts below authorised to discuss the child’s medical record with us

Yes

Contact 1: Name / Relationship to child / Telephone Number / Address (if different to child)

Contact 2: Name / Relationship to child / Telephone Number / Address (if different to child)

Medication

Does your child take any regular medication

If yes please specify name and dose (how many tablets per day) for all medications

Is your child allergic to any medication

If yes please list below

List other allergies/intolerances (pollen, animal hair, food)

Smoking

Does your child smoke

If yes what do they smoke (cigarettes/pipe/cigar/vape)

How many do they smoke per day

Would you like advice on quitting

Are you an ex-smoker

Approximately when did you quit

Exercise

Does your child exercise regularly

If yes, what exercise do you take and how often:

Communication Preferences

We may want to contact you about your child by e-mail, send appointment reminders to your mobile and leave messages on your answer machine, if you have one. Tick the boxes if you are happy to be contacted

e-mail

SMS

Answer Machine

Letter

Please tell us which method of contact listed above is preferred

Disability/Accessible Information Standard

Please use this space to tell us about any specific communication needs you have ie needing information in large print or deaf/blind. For further information visit https://www.england.nhs.uk/ourwork/accessibleinfo/

Data Sharing

Summary Care Record (SCR)

As you are registering with this practice, we would like to recommend that you take advantage of the Summary Care Record (SCR). The Core SCR includes important information about your health: Medicines you are taking, allergies you suffer from and any bad reactions to medicines.

You can also choose to have additional information included in your SCR, which can improve 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 and who should be contacted for more information about you.

You may need to be treated by health and care professionals outside of the practice who do not know your medical history. Having the additional information SCR can help the staff involved in your care access information more quickly, allowing them to make informed decisions about your healthcare. More information can be found by visiting www.nhscarerecords.nhs.uk

Tick this box if you wish to opt-in to the Core SCR

Tick this box if you wish to opt-in to the Core and Additional SCR

Tick this box if you wish to opt-out from the SCR

Medical Interoperability Gateway (MIG) Whilst the SCR mentioned above shares a very small portion of your child’s medical record across the whole NHS, the MIG shares a much broader view of their records but only with local NHS providers – and only when you give explicit consent at the point of care. For more information please visit https://healthcaregateway.co.uk/

Online Patient Access

Once your application to join our practice has been accepted you’ll be able to order your repeat medications and book appointments. This service is known as Systmonline. To register visit www.springfieldsmedicalcentre.co.uk or ask reception for an application form. You need to bring the completed form to reception then you’ll be given a username and password so you can create the online account.

Each individual will need their own username and password. You will be able to book an on-line TELEPHONE consultation, view and order your medication, view your test results, send the surgery a message.. You can also view your Summary Care Record unless you’ve chosen not to have one. You will also be able to see any allergies recorded, vaccinations, previous illnesses, hospital discharge summaries, appointment letters and referral letters

Ordering Medication

on-line Items that appear on your tick slip and medications that you have had from the surgery in the past will be listed on Systmonline.

Change of Contact Details

You can update us with your new address, telephone number, e-mail online. You can also consent to receiving text message reminders for things like appointments

How To Order Your Repeat Medication

For safety reasons, we do not take prescription requests over the telephone There are a number of ways you can order your medication:-

On-line via Systmonline (you will need a username and password)

e-mail – warccg.springfieldspx@nhs.net

Post your request to Springfields Medical Centre, Legh Street, Warrington WA1 1UG

Complete a prescription request form at the surgery

Your GP will routinely review your medication and may ask you to arrange a review with our Clinical Pharmacist. If you are due a medication review or health check and fail to attend, we reserve the right to reduce your medication until you have had your review.

Nominated Pharmacy

The majority of prescriptions can be sent electronically to a Pharmacy of your choice. Please let us know your preferred Pharmacy and we can add this to your record.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Springfields Medical Centre • Legh Street, Warrington, WA1 1UG.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.