Under 16 Registration Questionnaire

Please note: 
All new registrations require the completion of the GMS1 Form. Registrations cannot be processed without this.

Under 16 Registration Questionnaire
Please help us trace your child's previous medical records by providing the following information
If your child is from abroad
Armed Forces
Registering a child who is not your 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 or in residential children’s homes.

If you are registering a child under 5
Additional details about your child
Next Of Kin / Emergency contact
Carers 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 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.

Medical details

Has the child ever had any of the following conditions? If yes, please provide the year of diagnosis.

Does the child have Family History of any of the following?

If yes, please advise the family member/s who have the condition

Your child's health

Please tell us about your child’s smoking habits

Communication Preferences
Data Sharing

Summary Care Record (SCR)

As you are registering your child 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 child’s health: Medicines your child are taking, allergies they suffer from and any bad reactions to medicines.

You can also choose to have additional information included in your child’s SCR, which can improve the care your child receives. This information includes: Your child’s illnesses and health problems, operations and vaccinations they have had in the past, how they would like to be treated – such as where you would prefer your child to receive care; what support your child might need and who should be contacted for more information about them.

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

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/

The Accessible Information Standard (AIS)

Donor Registration Choices
Online Patient Access

Once your application for your child to join our practice has been accepted you’ll be able to order your child’s repeat medications and book appointments. This service is known as Patient Access. 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 emailed a registration letter within seven working days so you can create the online account. Please note you must have an email address to use this service and given consent to receive emails from Springfields Medical Centre. Full terms and conditions are available on the application form.

Electronic Prescription Service (EPS)

Once your child is registered…

You will be able to nominate a pharmacy to collect your child’s prescriptions from. EPS enables prescribers, such as GP’s and practice nurses, to send prescriptions electronically to 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 Information

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.

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.


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