Newborn baby patient registration

Patient’s Details

Title *

Miss

Master

Other

Please specify:

Please do not submit shortened forms of your child’s forename(s) or nicknames – their name must be as it appears on official documentation.

First Name(s) *

Surname: *

Sex: *

Female

Male

Indeterminate

NHS Number:

Home Address: *

Postcode: *

Next of Kin

Full Name: *

Date of birth:

Please use this date format: DD/MM/YYYY.

Relationship to child: *

Main Contact Number: *

Email Address: *

Any responses we send will go to this email address.

Mobile Phone Number:

Home Phone Number:

Can we contact you by text?

Yes

No

Can we contact you by email?

Yes

No

Ethnicity

Please specify the ethnic group you consider your child belongs to:

Please specify:

White British

White Irish

Other White background

Please specify:

White and Black Caribbean

White and Black African

White and Asian

Other Mixed background

Please specify:

Indian or British Indian

Pakistani or British Pakistani

Bangladeshi or British Bangladeshi

Other Asian background

Please specify:

Caribbean

African

Other Black background

Please specify:

Chinese

Other

Please specify:

First Language:

Previous Details

Previous address in UK:

Please include postcode.

Name and address of previous GP:

If you are from abroad

Registering with the NHS for the first time in the UK

Date you came to live in the UK:

Please use this date format: DD/MM/YYYY.

If you are returning from abroad

Previously been registered with the NHS in the UK

Date you left the UK:

Please use this date format: DD/MM/YYYY.

Date you returned to the UK:

Please use this date format: DD/MM/YYYY.

Supplementary Questions

I am not ordinarily a resident in the UK

Ordinarily Resident

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. Alternatively for more information go to www.nhs.uk/visitingengland.

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.

A parent/guardian should complete the form on behalf of a child under 16.

Signature: *

Print Name:

On behalf of:

Relationship to patient:

Date:

European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea

Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?

Yes

No

Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?

Yes

No

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.

EHIC/PRC

Please enter the details from your EHIC or PRC below.

Country Code:

3. Name:

4. Given Names:

5. Date of Birth:

6. Personal Identification Number:

7. Identification number of the institution:

8. Identification number of the card:

9. Expiry Date:

PRC validity period – from:

PRC validity period – to:

S1 Form

Do you have an S1 Form?

I have an S1 form (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.

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.

Nominate a Pharmacy

Chosen Pharmacy is:

Boots, Postmill Close, NR18 0NL

Well Wymondham – Market Street, 47 Market Street, NR18 0AJ

Boots, 35A Great Melton Road, NR9 3AB

Boots, The Old School, NR14 8AE

Other

Not sure where the closest pharmacy is?

Use the NHS Find a Pharmacy tool.

Other

Pharmacy Name: *

Pharmacy Address: *

Pharmacy Postcode: *

Your NHS Data Matters

The data held in your GP medical records is shared with other healthcare professionals for the purposes of your individual care. It is also shared with other organisations to support health and care planning and research.

If you do not want your personally identifiable patient data to be shared outside of your GP practice for purposes except your own care, you can register an opt-out with your GP practice. This is known as a Type 1 Opt-out.

Type 1 Opt-outs may be discontinued in the future. If this happens then they may be turned into a National Data Opt-out. Your GP practice will tell you if this is going to happen and if you need to do anything. More information about the National Data Opt-out (Type 2) is available by visiting: www.nhs.uk/your-nhs-data-matters

Please select one of the following to register a type 1 decision: *

Opt Out: I do not allow my identifiable patient data to be shared outside of the GP practice for purposes except my own care.

Withdraw Opt-Out (Opt-In): I do allow my identifiable patient data to be shared outside of the GP practice for purposes beyond my own care.

Summary Care Record

Your Summary Care Record is a short summary of your GP medical records. It tells other health and care staff who care for you about the medicines you take and your allergies.

This means they can give you better care if you need health care away from your usual doctor’s surgery, for instance in A&E or when you’re on holiday.

If you agree, we will include additional information in your Summary Care Record. This will help you get better care when you are away from the GP practice.

Consent *

I agree to having additional information in my Summary Care Record

I do not want additional information in my Summary Care Record

Are you sure? If you do not allow us to include additional information in your Summary Care Record, your care may be harmed if you get seriously ill.

What happens to my information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

I certify that the information I have provided is correct and consent to my child’s personal and medical information being used as stated above.

Signature: *

Date:

Tell us whether you accept cookies

Patient’s Details

Next of Kin

Ethnicity

Previous Details

If you are from abroad

If you are returning from abroad

Supplementary Questions

Ordinarily Resident

European Economic Area (EEA) Country

EHIC/PRC

S1 Form

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

Nominate a Pharmacy

Other

Your NHS Data Matters

Summary Care Record

What happens to my information?