Registration Form ( CHILDREN 0 - 15 YEARS)

Last Updated: 25/05/2022

Child Contact Details

Title

Gender *

Female

Male

First Names *

Surname *

Date of Birth *

Previous Surname

Town and Country of birth *

NHS Number *

Home Address *

Postcode *

Home Telephone Number

Mobile Number *

Email Address *

Previous GP

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

Name and Address of Previous GP *

If you are from abroad - date you first came to live in uk *

Your previous address in the uk *

If you are returning from the armed forces

please indicate if you have ever served in the uk armed forces and/or been registered with a ministry of defence GP in the UK or overseas:

Regular

Reservist

Family Member

ADDRESS BEFORE ENLISTING

SERVICE OR PERSONNEL NUMBER

ENLISTMENT DATE

If you need your doctor to dispense medicined and appliances*

*Not all doctors are authorised to dispense medicines

If you need your doctor to dispense medicined and appliances*

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

i would have serious difficulty in getting them from a chemist

NHS Organ Donor Registration

I want to register my details on the NHS Organ Donor resister as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply

Any of my organs and tissue

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

NHS Blood Donor Registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

Thick here if you have given blood in the last 3 years

Yes No

My preferred address for donation is : (only if different from above, e.g. your place of work)

Information About Your Child

Parents Details

Mother's Full name *

Mother's contact number *

Mother's home address *

Same as above

Different from above

If different from above, please specify

Mother's email address *

Father's full name *

Father's contact number *

Father's home address *

Same as above

Different from above

If different from above, please specify

Father's email address *

Person with parental responsibility *

Mother

Father

Both

Other

If other, please write name, surname, contact number, relationship to patient

Medical Information

Key Support Worker

Does your child have a Key Support Worker? *

Yes No

If yes, do you give consent for us to contact your child's Key Support Worker?

Yes No

Please provide Key Support Worker details (name, contact number)

Contacting You

Preferred email address for contact

Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders. *

Yes No

Proof of Identity and Address Provided

Patinet access to online services

Terms and Conditions: The Practice will not allow misuse of the online system and will monitor usage by individual patients. Where it is considered that a patient is misusing the system, access will be blocked.

Please select if you wish to obtain online access to *

Allergies and Medication

Immunisations History

Results (including: blood test results, urine, swabs, BP readings etc.)

Problems (including present and past medical history)

none of the above

Nomination of pharmacy for EPS

EPS (Electronic Prescription Services)

Would you like to nominate a pharmacy for your EPS? *

Yes No

Hiren - Next door pharmacy *

Yes No

Other pharmacy? Please specify Name and Address *

Signature

Signature on behalf of patient *

Date *

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Cookies on the Springfield Medical Centre website

Registration Form ( CHILDREN 0 - 15 YEARS)

Further Information

Connect With Us