THE KEATS GROUP PRACTICE REGISTRATION FORM PLEASE COMPLETE IN BLOCK CAPITALS PERSONAL BACKGROUND INFORMATION

Transcription

1 Registration checked by: Date: 11 & Under THE KEATS GROUP PRACTICE REGISTRATION FORM PLEASE COMPLETE IN BLOCK CAPITALS PERSONAL BACKGROUND INFORMATION Male Female Has your child ever been treated at this practice before? Yes No Surname: Forename: Previous Surname: Calling Name: Date of Birth: / / Mr /Miss/ Other: Age: Home Address: Postcode: Home Telephone No: Mobile NO: 10 digits NHS Number: D Preferred Contact: Home tel [ ] Work tel [ ] Mobile [ ] Letter to home address [ ] If you would like this letter or information in an alternative format, for example large print or easy read, or if you need help with communicating with us, for example because you use British Sign Language, please let us know. You can call us on or keats.group@nhs.net 1

2 Is your child registered disabled? YES [ ] NO [ ] If yes please give details of your disability A carer is anyone who cares, unpaid, for a friend or family member who due to illness, disability, a mental health problem or an addiction cannot cope without their support. IS your child a carer for someone? Yes [ ] No [ ] If yes are they registered at the practice? YES [ ] NO [ ] The name of the person for whom they care Does your child have a carer? Yes [ ] No [ ] If yes please provide details FAMILY DETAILS Father s Name: Mother s Name: NEXT OF KIN / EMERGENCY CONTACT Full Name: Relationship: Contact Telephone No: Address: Is this person? Emergency Contact [ ] and/or Next of Kin [ ]

3 ABOUT YOUR CHILD S ETHNIC GROUP To which of these ethnic groups do you feel your child belongs to? Please tick one box I do not wish to answer WHITE British / Mixed British Irish Other ASIAN Indian / British Indian Pakistani / British Pakistani Bangladeshi / British Bangladeshi Any other (non-mixed) Asian background, please state MIXED White and Black Caribbean White and Black African White and Asian Any other (mixed) background, please state BLACK Black British Caribbean African Any other (non-mixed) Black background please state OTHER ETHNIC GROUP Chinese Vietnamese North African Arab / Iranian Arab Other European (non-mixed), please state Other non-european (non-mixed), please state Please state country of origin Main Language Spoken Will you or your child need an interpreter? Yes [ ] No [ ]

4 YOUR CHILD S IMMUNISATION HISTORY This is the schedule of child immunisations in the united kingdom Routine Childhood Immunisation Program When to Immunise Diseases Protected Against Vaccine Given Two Months Old Diptheria, Tetnus, Pertussis (Whooping Cough), Polio and Haemophilus Influenzae Type b (HIB) Pneumococcal Infection DTap/IPV/Hib and Pneumococcal Conjugate Vaccine (PCV) Three Months Old Four Months Old Around 12 Months Old Around 13 Months Old Three Years Four Months to Five Years Old Thirteen To Eighteen Years Old Diptheria, Tetnus, Pertussis, Polio and Haemophilus Influenzae Type b (Hib) Meningitis C (meningococcal group c) Diptheria, Tetnus, Pertussis,Polio and Haemophilus Influenzae Type b (HIB) Pneumococcal Infection Haemophilus Influenzae Type b (Hib) Meningitis C Measles, Mumps and Rubella (German Measles) Pneumococcal Infection Diptheria,Tetnus,Pertussis and Polio, Measles, Mumps and Rubella Diptheria,Tetnus, and Polio, DTaP/IPV/Hib and Men C DTap/IPV/Hib and Men C Hiib/Men C MMR and PCV DTaP/IPV OR dtap/ipv and MMR Td/IPV The following tables need to be completed if your child has been immunised in the UK please fill in the UNITED KINGDOM IMMUNISATION HISTORY if your child has been immunised outside of the UK Please fill in the NON UK IMMUNISATION HISTORY table It is important to record all details of your child s immunisations. We will not be able to register your child without this information!

5 UNITED KINGDOM IMMUNISATION HISTORY IMMUNISATION DATE GIVEN GP SURGERY / PRIVATE / 2 MONTHS First DTaP/IPV/Hib 1 st PCV (Pneumococcal) First meningitis B vac 1 st Rotavirus(cqrs) 3 MONTHS 2 ND DTaP/IPV/Hib 2 ND Rotavirus(cqrs) 4 MONTHS 3 RD DTaP/IPV/Hib 2 nd Men B vac 2 nd PCV Between 12 and 13 months Hib/Men C (CQRS+NHSE) MMR (1 st dose) 3 rd PCV (Pneumococcal) 3 rd meningitis B 3 years and four months MMR (2 nd dose) DTaP/IPV or dtap/ipv (preschool booster) Other (non routine) Please list

6 NON UK IMMUNISATION HISTORY VACCINE DR, or Private Date Given (dd/mm/yyyy) Diphtheria Childs Age (when given) Vaccine Known As DTaP Pertussis Tetanus Polio IPV Haemophilus influenzae Type B HiB Meningococcus MenC Rotavirus Rotavirus (RV) Pneumococcus PCV Measles MMR Mumps Rubella Human papillomavirus HPV Tuberculosis Typhoid fever Hepatitis B Hepatitis A Influenza (seasonal) Varicella (chickenpox Yellow fever Tick-borne encephalitis Typhim Vi, Typherix or Ty21a BCG ViATIM, Hepatyrix IIV or LAIV VZV 17D TBE

7 Please Enter Your Child s Height & Weight And Provide A Urine Sample If Your Child Is Aged 5 Years Or Over Height : CM Weight: KGS ONLY TO BE DONE IF OVER 5 YEARS-Urine Sample Taken: Is your child on any regular medication? Yes / NO If yes please make an appointment with reception to see a Clinician. PLEASE NOTE: Repeat prescriptions will NOT be issued until you have seen a Doctor or Nurse Practitioner Allergies: Any other medical problems, which require medication, or major operation(s):

8 Recording Consent of New Patients for Data Sharing Initiatives in Camden Camden Integrated I want to: Digital Record Local Initiative Camden Integrated Digital Record Opt out of CIDR. (CIDR), enables your Camden care providers, when they are treating IF YOU WISH TO OPT OUT OF you, to view the relevant information CIDR PLEASE ASK RECEPTION about the care you receive, and so FOR THE SPECIFIC OPT OUT give you the best possible care. FORM Summary Care Record National Initiative If you have a Summary Care Record your health care providers can view your medication (last 12m) bad reactions to medicines allergies when you re admitted to hospital, when treating you in an emergency, or when your practice is closed. I want to have a Summary Care Record. I do not want to have a Summary Care Record. **I agree to the above registration process in full. *Parent/Guardian Signature: Print: Date: / / For more information you can pick up a practice leaflet or log on to our website. For more information you can pick up a practice leaflet or log on to our website.

9 FOR OFFICE USE ONLY Form checked by Has the gms1 form been fully completed YES [ ] NO [ ] Has the gms1 form been passed to the Patient Services Manager YES [ ] NO [ ] Has the form been checked and fully completed YES [ ] NO [ ] Has patient been informed of named GP YES [ ] NO [ ] Consent forms have been completed YES [ ] NO [ ] Has the patient any access needs YES [ ] NO [ ] Has the urine sample been tested YES [ ] NO [ ] Has a copy of the practice leaflet be given YES [ ] NO [ ] Has the immunisation record been completed YES [ ] NO [ ]