Channel View Medical Group (All Sites) – 01626 774 656

New Patient Registration Form for Newborns

Which branch would you like your Child to be registered at?(Required)

Your Child's details

Name(Required)
Date of Birth(Required)
Male/Female(Required)

Parent or Guardian details

MUST be a registered patient at this practice and residing at the same address.
Mother or Guardian name
By providing a mobile number and/or email address, we assume your consent for contacting you by SMS and/or email
Father or Guardian name
By providing a mobile number and/or email address, we assume your consent for contacting you by SMS and/or email
Email
By providing a mobile number and/or email address, we assume your consent for contacting you by SMS and/or email
Please provide the names, dates of birth and relationship to the patient you are registering

Your Child's details continued

Ethnicity(Required)

Religion(Required)

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

Prescriptions - Electronic prescribing

If you would like your child's prescriptions to be sent electronically, please provide details of the pharmacy you would like to use:

Sharing your Child's health record

What is your health record?

Your health record contains all the clinical information about the care you receive. When you need medical assistance it is essential that clinicians can securely access your health record. This allows them to have the necessary information about your medical background to help them identify the best way to help you. This information may include your medical history, medications and allergies.

Why is sharing important?

Health records about you can be held in various places, including your GP practice and any hospital where you have had treatment. Sharing your health record will ensure you receive the best possible care and treatment wherever you are and whenever you need it.

Choosing not to share your health record could have an impact on the future care and treatment you receive.

Sharing Out - Do you consent to your GP Practice sharing your Child’s health record with other organisations who care for them?(Required)
Sharing In – Do you consent to your GP Practice viewing your Child's health record from other organisations that care for them?(Required)
Your Summary Care Record (SCR) - Do you consent to your child having an Enhanced Summary Care Record with Additional Information?(Required)

Parent or Guardian Signature

You will be asked to sign this form when you visit the practice and provide ID and proof of address and a birth certificate of your Child.
Please enter your name here to confirm you have completed the form and you confirm that the information you have provided is true to the best of your knowledge
Today's date(Required)
Consent(Required)

Date published: 23rd August, 2021
Date last updated: 2nd September, 2021