Under 16s Registration Form

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Patient's Details

Information we need to register you with the practice
Please note all fields marked with a * are mandatory for your registration

 

By supplying us with your email and mobile you agree to us contacting regarding your health

by supplying us with your email and mobile you agree to us contacting regarding your health

PRACTICE MAP & HOME LOCATION

By proceeding with your registration you are confirming that you checked your home post code (https://www.westhampsteadmedicalcentre.com/pages/Practice-Map) & that you are aware & agree to the out of area policy.

Ethnicity
Emergency Contact
Previous Details
Please include postcode
If you are from abroad
Please use this date format: DD/MM/YYYY
If you are returning from abroad

Previously been registered with the NHS in the UK

Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

Please enter the details from your EHIC or PRC below.

Immunisation History
Please include dates.
Medical History
Please include dates.
Please include dates.
Please include dates.

HIV:All new patients above the age of 16 are eligible to have a HIV blood test. If you would like this please request a blood test form from reception

Chlamydia: If you are sexually active you can do a self-taken Chlamydia test. These are available in the toilets of the surgery and can be handed in to reception.

 
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Patient online access

We encourage all patients to obtain online access to their records.

This will allow you to use patient apps like the NHS App which will allow you to: book appointments, make online consultations with us for simple requests using eConsults, request repeat prescriptions and look up information on your medical records like immunisations, blood test and other results with comments  as well as update donation preferances.

For us to be able to enable this functionality we need to confirm your identity so please ensure you upload your photo identification and proof of address as requested at the end of this form (page 4).

Summary Care Record

Summary Care Record (SCR)

The Summary Care Record (SCR) system is designed to help both your GP and any emergency staff you contact when the surgery is closed to treat your health needs more efficiently.

Your information will be shared between your GP practice, our local hospital and Out Of Hours service. This will enable your GP surgery to access results and any visits you have at the hospital quickly and efficiently, but it also means that if you have an emergency and contact the Out Of Hours service or visit A&E they will have access to your current medications as well as allergies and are better able to treat you.

If you do not return this form, a Summary Care Record will be created for you based on implied consent

NHS Organ Donor Registration

NHS Organ Donor Registration

At this stage we will be mainly noting your preferences internally. However, if contacted by the transplant service we would notify them of your choices and therefore by ticking a box you are confirming your agreement to the organ/tissue donation.

Please leave this section blank if you do not wish to register.

PLEASE CONTACT THE SERVICE IF YOU WISH TO REGISTER by either visiting the website www.uktransplant.org.uk or calling 03001232323

NHS Blood Donor Registration

NHS Blood Donor registration

At this stage we will be mainly noting your preferences internally. However, if contacted by the blood & transplant service we would notify them of your choices and therefore by ticking a box you are confirming your agreement to the organ/tissue donation.

Please leave this section blank if you do not wish to register.

PLEASE CONTACT THE SERVICE IF YOU WISH TO REGISTER by either visiting the website www.blood.co.uk or calling 03001232323

PLEASE NOTE: The form will not allow you to complete/submit until all the mandatory sections are complete which are marked with a red asterisk* & error message should also appear but some web browers may not properly display this.

I certify that the information I have provided is correct.

Please include full name & relationship to the patient
Please include contact number and email
Identification Upload

Patient Identification

To fully register you at the practice, we need Two forms of Acceptable ID (if not possible, please let us know).

We will not store these documents and we will securely delete / destroy them after our initial verification.

OPTIONAL: Photo of your face to add to your records to help us identify you (if you agree)

Acceptable Identification: Photo Driving License, Passport, Tenancy agreement, Mortgage statement, Bank statement, Utility bill (date within the past 3 months) etc.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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