Child (Under 17 years) Registration Form

Please be aware that the Practice uses text messaging communications as part of your healthcare. Do you accept this service? *

Accept Text Messaging Services

Decline Text Messaging Services

Failure To Attend Appointments: The practice follows a policy for patients who fail to attend appointments. All appointments not attended will be recorded on your medical record. Your GP will discuss these with you and they have the right to remove you from the Practice if you repeatedly fail to attend. KEEP IT OR CANCEL IT! *

Please tick here to confirm you have read this information

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Read & understood

Immunisations

Please enter the exact dates of your child's immunisations including each dose of each vaccination.

Child Health Services

Thank you for registering with us. Please complete this section so we have as much information to ensure all children have access to Community Healthcare Services relevant to their ages.

Child's current Nursery or School (enter n/a if they do not attend) *

Child's previous Nursery/School (if any)

Name of Health Visitor / School Nurse (if known)

Has the child ever been subject of a child protection plan? *

Yes No

If yes, when?

Has the child ever been a 'looked after' child (i.e. in foster care or in a children's home)? *

Yes No

Parent 1 Full Name *

Parent 1 Date of Birth *

Parent 1 Address (if different from child's)

Parent 1 Telephone Number *

Parent 2 Full Name *

Parent 2 Date of Birth *

Parent 2 Address (if different from child)

Parent 2 Telephone Number *

Please list any siblings including their dates of birth

Opt Out Form for Sharing Data from your Medical Records

There are two data sharing projects currently in progress and these are: • SCR – Summary Care Record • YCC – Your Care Connected (formally known as Central Care Record) It is important to note that each of these projects run a separate opt out system. Therefore if you wish to opt out of one or more of these projects please complete the form below.

SCR - Summary Care Record: Used in emergency care this record will contain information about any medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had, to ensure those caring for you have enough information to treat you safely. *

SCR - Accept this service

SCR - Decline this service (9ND0)

YCC – Your Care Connected (Formally - Central Care Record): Information such as allergies, medication, test results, alerts, diagnosis, treatment past & present and end of life care plans will be available. Specifically for use by services such as GP practices in Birmingham, Solihull and Sandwell, local hospitals, ambulance service, social care staff, community health and mental health. *

YCC - Accept this service

YCC - Decline this service (9Nd1)

SUPPLEMENTARY QUESTIONS | 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 tick one of the following boxes:

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.

Are you a parent or guardian, filling out this form on behalf of a child under 16?

Name parent or guardian

Relationship to patient:

Signed

Date

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 the GP practice, including at hospital).

Do you have a non-UK EHIC or PRC?

Yes No

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

a) From:

b) To:

Please tick if 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). Please give your S1 form to the practice staff.

I have an S1 form

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.

Further Information