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New Patient Registration Form (Child)

Before you complete this form, please have ready:

  1. Your childs birth certificate
  2. Your childs immunisation history

OUT OF AREA REGISTRATION (without home visits)

Information for consideration prior to registration.

You have requested to register with our Practice as an ‘Out of Area’ patient. You live outside the practice boundary (catchment area) and we want to make you aware of what this means for you under this type of registration.

We may decide that it is not in your best interests or practical for you to be registered.

Please read the details below and give careful consideration to your request to register with our Practice. An important consideration you should make is that we are not required to provide you with a home visit.

You may on occasion, develop an urgent illness or injury at home that means attending our Practice would not be possible.

If you have an urgent care need we will ask you to call NHS 111 and they will put you in touch with a local service (this may be a face to face appointment with a local healthcare professional or a home visit where necessary).

In these circumstances NHS 111 will direct you to the local service that has been established by NHS England for patients such as you. This local service could be a GP practice near to where you live, the local walk-in or urgent care centre, A&E or minor injuries unit.

If this is in the out-of-hours period when GP surgeries are normally closed – between 6:30pm and 8:00am weekdays, bank holidays or weekends – NHS 111 will direct you to the local out-of-hours provider.

If your application is considered the practice will only register you without home visits if it is clinically appropriate and practical in your individual case. To do this we may:

  •  Ask you or the practice you are currently registered with questions about your health to help decide whether to register you in this way 
  • Ask you questions about why it is practical for you to attend this practice (for example, how many days during the week you would normally be able to attend)

If accepted, you will attend the Practice and receive the full range of services provided as normal other than home visits, you may not be able to access other certain services also such as

  • District Nurse Services
  • Mental Health Services
  • Social Care Services
  • Health Visiting Services

Also, if you are an out of area patient we will review your medical notes on a 3 monthly basis to ensure we are providing a safe clinical service that is tailored to your needs. If we feel that we cannot meet your health needs we will ask you to register at a GP closer to your home address and we will remove you from our list.

If you are happy with this information, please sign below and continue with the registration form.

Patients Details

Information we need to register your child with the practice
Please note all fields marked with a * are mandatory for the registration

Please answer the following questions about your child:

Ethnicity and Religion
Language
Medical History

If your child is on medication, please make an appointment to see the doctor when you have completed the registration. 

Immunisation History

Please select each immunisation your child has had, and provide us with details where possible.

Development Checks

What happens to my child's 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 child's GP in order to provide continued healthcare and obtain treatment for them.

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 have access to your child's records are 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 their 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.

Privacy Consent

This form collects personal and medical information about your child. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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