WHMP Newborn Baby Patient Registration Form

TITLE *

SURNAME *

FIRST NAME *

MIDDLE NAME(S)

PREVIOUS NAME/SURNAME

DATE OF BIRTH *

BIRTH TOWN *

BIRTH COUNTRY *

NHS NUMBER

CURRENT ADDRESS *

POSTCODE *

Parent and Guardian Details (1)

FULL NAME *

RELATION TO CHILD *

MOBILE PHONE NUMBER (PLEASE PROVIDE HOME NUMBER IF NO MOBILE) *

HOME PHONE NUMBER

EMAIL ADDRESS

DO YOU WANT TO RECEIVE EMAILS FROM THE PRACTICE? *

I do wish to receive emails from the practice

I do not wish to receive emails from the practice

ARE YOU THE CHILD'S LEGAL PARENT/GUARDIAN?

Yes No

DO YOU WANT TO BE CONTACTED IN THE EVENT OF AN EMERGENCY?

Yes No

Parent and Guardian Details (2)

FULL NAME

RELATION TO CHILD

MOBILE PHONE NUMBER

HOME PHONE NUMBER

EMAIL ADDRESS

DO YOU WANT TO RECEIVE EMAILS FROM THE PRACTICE?

I do wish to receive emails from the practice

I do not wish to receive emails from the practice

ARE YOU THE CHILD'S LEGAL PARENT/GUARDIAN?

Yes No

DO YOU WANT TO BE CONTACTED IN THE EVENT OF AN EMERGENCY?

Yes No

Ethnic Origin and Main Language Spoken

PLEASE SELECT WHICH ETHNIC GROUP YOU BELONG TO *

OTHER ETHNIC BACKGROUND

DO YOU SPEAK ENGLISH?

Yes No

OTHER LANGUAGE(S) SPOKEN

DO YOU REQUIRE AN INTERPRETER?

Yes No

Baby's Medical Information

WERE THERE ANY COMPLICATIONS AT BIRTH THAT THE GP SHOULD BE AWARE OF?

DOES YOUR BABY HAVE ANY ALLERGIES THAT YOU ARE AWARE OF? (IF SO, PLEASE SPECIFY)

Repeat Medication

If your child is on any repeat medication, please submit an Engage Consult to speak to a GP or Clinical Pharmacist within six weeks of registering.

We are unable to prescribe repeat medication without an initial consultation. Please have a list of current medication with you during your consultation.

Summary Care Record and Oxfordshire Care Summary

All patients registered with a GP have a Summary Care Record (SCR), unless they have chosen not to have one. The information held in your Summary Care Record gives health and care professionals, away from your usual GP practice, access to information to provide you with safer care, reduce the risk of prescribing errors and improve your patient experience.

Your Summary Care Record contains basic information about allergies and medications and any reactions that you have had to medication in the past.

Summary Care Record - enables NHS Hospitals and Minor Injury Units across England access to your current medications, allergies and current health problems *

I do wish my child's information to be shared through the Summary Care Record

I do not wish my child's information to be shared through the Summary Care Record

Oxfordshire Care Record - enables hospitals and minor injury units across Oxfordshire access to your current medications, allergies, any bad reactions to medication and main current health problems *

I do wish my child's information to be shared through the Oxfordshire Care Record

I do not wish my child's information to be shared through the Oxfordshire Care Record

Patient Proxy Online Access Registration

Patient Access allows you proxy access to view some of your child's electronic medical record online and request repeat prescriptions.

In order to access your child's details online you will need to bring photographic ID and proof of address for you and your child to the practice.

I WOULD LIKE TO SIGN UP TO PATIENT PROXY ACCESS FOR MY CHILD AND I FULLY UNDERSTAND THAT I NEED TO BRING THE ABOVE MENTIONED ID INTO THE PRACTICE TO COMPLETE THE PATIENT ACCESS REGISTRATION

Yes No

Parent/Guardian Disclaimer

The information provided above is correct to the best of my knowledge.

I have read and understood the information enclosed and have indicated my consent preferences throughout this form.

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Further Information