New Patient Registration - Baby

Please note that we can only register babies if their parent/guardian is currently registered as a patient here

Before new patients can be taken onto our list, registration forms and a patient history form must be completed and you will have to attend the practice for a simple health check.

If this is your first time registering in the UK you should bring with you proof of your eligibility, for example a document bearing your NHS number or, failing that, your passport.

Before any medication can be issued you must be seen by one of the doctors or nurse practitioners.

Please ensure you have read the information in these downloads below completing the online registration form below:

Your Child's Details

First Name

Middle Name

Last Name

Date of Birth

Gender

Town and country of birth

NHS Number

Address

Home Telephone

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

Your Name

Your child's previous address in UK

Relationship

Name of previous GP practice while at that address

Address of previous GP practice

Address

Home Telephone

If you are from abroad

Work Telephone

Your child's first UK address where registered with a GP

Date your child first came to live in UK

Mobile Telephone:

If you need your doctor to dispense medicines and appliances*

* Not all doctors are authorised to dispense medicines

If previously resident in UK, date of leaving

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

NHS Organ Donor registration

Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision.

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

Any of my organs and tissue or

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

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.

Are you:

A refugee

An asylum seeker

* Not all doctors are authorised to dispense medicines

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:

NHS Blood Donor registration

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

Country Code:

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

All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.

Have you given blood in the last 3 years

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). 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.

Your Child's Registration Information

Ethnicity

If other please provide details

Religion

If other please provide details

Your Child's Communication Needs

What is your main spoken language?

Do you need an interpreter?

Does your child have any communication difficultiesIf Yes please specify below

Your Child's Medical History

Has your child suffered from Asthma?

Has your child suffered from Diabetes?

Has your child suffered from Depression?

Housing

Has your child suffered from Epilepsy?

Any other conditions, operations or hospital admission details:

If your child is currently under the care of a Hospital or Consultant outside our area, please tell us here:

Your Child's Family History

Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent

Asthma

COPD

Epilepsy

Heart Disease

Stroke

Blood Pressure

Diabetes

Kidney Disease

Liver Disease

Depression

Thyroid

Cancer

Other

Your Child's Allergies

Please record any allergies or sensitivities below

Your Child's Current Medication

Are they on regular medications?

Please check and include as much information about your child’s current medication below. If they have a previous repeat medication list please give this to us & they may need a medication review appointment

Electronic Prescribing

If you would like your child’s prescriptions to go electronically, please provide details of the pharmacy you would like to use:

Sharing Your Health Record

Please ensure you read the "Sharing Your Health Record" download at the top of this page

Do you consent to your GP Practice sharing your Child’s health record with other organisations who care for them?

Do you consent to your GP Practice viewing your Child’s health record from other organisations that care for them?

Your Summary Care Record (SCR)

Do you consent to your child having an Enhanced Summary Care Record with Additional Information?

Parent or Guardian Details

Your Name

Relationship

Address

Home Telephone

Work Telephone

Mobile Telephone:

Do you consent to being contacted by SMS on this number

Do you consent to being contacted by email at this address

It is your responsibility to keep us updated with any changes to your telephone number, email & postal address. We may contact you with appointment details, test results or health campaigns

Family Registered With Us

To Complete your registration please provide a copy of your child's Red Book immunisation Page either in person at the practice or by email LECCG.Parkside@nhs.net

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 Parkside Medical Centre, Boston • Tawney Street, Boston, Lincolnshire, PE21 6PF.

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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New Patient Registration - Baby

Please note that we can only register babies if their parent/guardian is currently registered as a patient here

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