West Hampstead Medical Centre

Online New Patient Registration for Children (under the age of 16 years)

Dear Patient,

Please kindly take a few minutes to fully complete this form as best you can.

To fully complete the registration process please email to us one proof of photo identification (i.e. passport/UK driving license/national idenfication card/travel document) and one proof of address (i.e. utility bill/telephone bill/credit card bill/tenancy agreement/council tax bill) dated within the last 4 months. Please email the images of your documents (i.e. scanned copies/pictures) in a standard format (i.e. pdf/jpeg) to register.whmc@nhs.net.

If you cannot email to us the above documents please do come in person and we will photocopy your documents and attach them to your file.

PLEASE ALLOW 3-4 WORKING DAYS TO PROCESS YOUR ONLINE REGISTRATION THEN BOOK AN APPOINTMENT IF YOU REQUIRE MEDICATION. IF YOU REQUIRE MEDICATION SOONER PLEASE SPEAK TO RECEPTION.

N.B Please be aware that if you are on highly addictive or controlled medications (i.e. tramadol, diazepam, temazepam etc) that we are unable to prescribe these medications until we have your old medical records, so please liaise with the reception to ensure we have these before booking an appointment. Please also note that we do not prescibe out of accordance with national and local medicines management guidelines.   

For Details about the Summary Care Record, CIDR and Care.data please go to the following links:https://digital.nhs.uk/summary-care-records, https://cidrportal.nhs.uk/

*Please ensure you complete all the mandatory sections in order to be able to submit and process the application form. All the mandatory sections are starred * 

PLEASE NOTE CHILDREN WILL ONLY BE RESGISTERED IF ONE OF THEIR PARENTS/MAIN CARER ALSO IS AT OUR SURGERY.

Please note that if you are outside of the practice map area and are likely to require home visits i.e. housebound/mobility issues, then please register with a practice more local to you.

1Patient Details

Title*Please Choose...Mr/MasterMiss

First Name*

Surname*

Previous name(s)

Date of Birth*

Place of Birth (Town and Country)*

Current Home Address*

Post Code*

Home Telephone Number

Mobile Number (Please also indicate whom this number belongs and their name to i.e.mother...)*

EmailBy giving us your email and mobile details you permit us to send you emails or texts relating to your clinical care (i.e. if you request us to send you a result).

Please identify whom this email belongs to:

Name of Next of Kin (Emergency Contact in the UK)*

Relationship to the patient (i.e. mother)*

Their Phone Number*

2Please help us to trace your previous medical records by providing the following information

Your previous address in the UK (please advise us here also if you have no previous UK address)

Name of previous doctor (NHS GP) while at that addressThis includes the name of the GP surgery/medical centre/health centre/medical practice

Address of previous GP

3If you are from abroad (please go to the section if this does not apply to you)

Your first address where you registered with a GP

If previously resident in the UK, the date of leaving

Date you first came to live in the UK*Please ensure you complete all mandatory sections in order to be able to submit/process the application. All mandatory sections are starred *

4Background information

How would you describe your(the patient's) ethnic background? (this is not necessarily the same as nationality or country of birth)

White British

Black: African/Afro-Caribbean/Black British

Middle Eastern/North African

South East Asian eg Bangaldeshi

Other Asian

White & Asian

White & Black

White & Other

Other White

Other Black

If you chose 'other' as your ethnic background, please describe in your own words your ethnic background

If English is not your or your parents first language, will you need an interpreter?

If need an interpreter which is your main spoken language(s)?

Are you a carer i.e. do you look after a friend or relative who is sick or disabled or has a significant mental problem or special needs (including a parent or guardian of a child)

Yes

No

Are you cared for by others? i.e. do you have a friend/relative who helps you live your day to day life

Yes

No

5About your health

Have you had ANY operations/surgery or suffered from other significant illnesses ? (if so please list below the details including dates)

Do you have ANY known ALLERGIES? (please include medication and non-medication i.e nuts etc)*Please Choose...NoYes

Please give details of all your known allergies below including the type of reaction (if known i.e rash or anaphylaxis)

Are you taking any medications? (this includes the contraceptive pill and occasional use medications as antihistamines/inhalers)*Please Choose...NoYes

If you are on any medication(s) please list their names and doses, frequency plus any other details

6Immunisation

Please either:(A) list below all the immunisations you have had including dates or (B) Send us the images of your immunisations documents to register.whmc@nhs.net or (C) drop to us your documents at the surgery

7Family Health History

Have any close family members (parents, siblings, aunts, uncles and grandparents) suffered from any of the following illnesses

Heart Problems

Stroke

Diabetes

Asthma

Cancer

Other Hereditary Illnesses

If they do please give further details including who, what and the approximate age of onset?

8FORM COMPLETION SIGNATURE

Signature of*:Please Choose...ParentOther Legal Guardian

Please confirm the full name of the person completing this form (this will act as your signature and in doing you are also confirming that all the information provided is accurate)*

Date completed*

9Supplementary questions for all patients whom are not ordinarily resident in the UK (please go to the section if this does not apply to you)

Anybody in England can register with a GP practice & receive free medical care from the practice. However, if you are not 'ordinarily resident' in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of 'indefinite leave to remain' in the UK. Some services such as diagnostic teats of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges. You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment,

Please tick one of the following boxes

(A) I understand that I may need to pay for the NHS treatment outside of the GP practice

(B) I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge ("the Surcharge"), when accompanied by a valid visa. I can provide documents to support this when requested.

(C) I do not know my chargeable status

10Summary Care Record

You will be automatically opted in to the summary care record unless you tick the below box. This record provides basic information of allergies, medications & demographics details from the GP record to other hospitals for urgent care

11CIDR (Clinical Integrated Digital Record)

This is a local digital record which contains medical and social information similar to the Summary Care Record but in addition has useful information such as upcoming appointments, test results, conditions & diagnosis. This system is used both in hospitals and general practice to improve care patients receive. Having key medical information available in an emergency can save lives.We encourage all patients to allow creation of and access to this record. Should you wish to opt out please contact the surgery.Please tick here to consent for West Hampstead Medical Centre to access the record on your behalf.

12Patient Participation Group

Please tick if you are happy for the surgery to email/text you about developments at the surgery and Open PPG meetings (you can withdraw consent in writing at any time)

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Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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