New Child Patient Registration Form - The Barcellos Family Practice

Title *

Surname *

Forename (s) including middle name if applicable *

Previous Surname (if applicable)

NHS number *

Date of Birth (DD/MM/YYYY) *

Gender *

Female

Male

Non-binary

Unable to answer

Prefer not to say

Full Current Postal Address including Post Code *

Key Safe Number (if applicable)

First Line and Post Code of Previous Address *

Parent/Guardian Name *

Relationship to patient *

Next of Kin Telephone Number *

Consent to receive communications

If any of the details on this form change in the future, please inform us. In accordance with the Data Protection Act, the Practice needs consent from any patient for us to leave a message, send a text or information regarding their medical treatment. By providing the information on this form you are consenting to be contacted about your medical needs.

This requests your consent to begin communication with you by text or email. *

I consent to the practice contacting me by text message or email for the purposes of health promotion, practice news and for appointment reminders

I acknowledge that appointment reminders by text are an additional service and that they may not be sent on all occasions but that the responsibility for attending appointments or cancelling them still rests with me.

Text messages are generated using a secure facility, but I understand that they are transmitted over a public network onto a personal telephone and as such may not be secure.

I understand I can cancel the text message facility at any time.

Additional Information Required for your Patient Record

Please help us trace your previous medical records and enable us to provide the best possible healthcare to suit your needs by providing the following information

Carer Information

Patient's Medical History

Please provide as much information as possible as this will help your GP provide the best care.

Consent and Data Sharing

If any of the details on this form change in the future, please inform us. In accordance with the Data Protection Act, the Practice needs consent from any patient for us to leave a message, send a text or information regarding their medical treatment. By providing the information on this form you are consenting to be contacted about your medical needs. The Barcellos Family Practice uses SystmOne clinical software. This enables us to share your record with any other NHS organisations who are involved in your healthcare.

Data Sharing Consent Choices (Summary Care Record & Dorset Shared Record)

To maintain continuity of clinical care, we upload certain medical information so that it is available to other healthcare organisations (e.g. Emergency Departments). Please download and view this information leaflet, which details which part of your record is extracted and how it is used to help other NHS organisations.

If you wish to OPT OUT, please indicate below.

Barcellos Family Practice: New Child Registration Form

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Barcellos Family Practice: New Child Registration Form

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