New Patient Questionnaire - Child Under 16

You will also need to complete the Patient Registration Form to register at the practice.

Last Updated: 19/05/2021

Your Details

Full Name *

Date of Birth *

Has the patient been registered within the NHS before? *

Yes No

If no please state date entered UK

Home Phone Number

Mobile Phone Number *

Work Phone Number

Email Address *

Contacting You

Do you consent to receiving SMS messages? Please note: The practice’s preferred method of recall is by letter, and when appropriate, by text *

Yes No

Next of Kin (Parent or Guardian)

Full Name *

Address and Telephone Number

Relationship

Information About You

Communication Needs

Medical Information

Sharing Your Health Record

Your Health Record: Do you consent to your GP Practice sharing your health record with other organisations who care for you? *

Yes No

Your Health Record: Do you consent to your GP Practice viewing your health record from other organisations that care for you? *

Yes No

Your Summary Care Record (SCR): Do you consent to having an Enhanced Summary Care Record with additional information? *

Yes No

Online Access

(Please note this is link to the parent/guardians online account)

I wish to have online access to: Please tick all that apply *

View and book appointments

View and request medication

Access my coded medical record (contains any medical codes that have been recorded)

Access my full medical record (contains medical codes and any free text that has been recorded)

Access my Summary Care Record

I consent to my username and password for online access being sent to me by SMS, email or post

Yes No

Signature

I confirm that the information I have provided is true to the best of my knowledge.

Signed on behalf of patient

Yes

Signature *

Date *

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New Patient Questionnaire - Child Under 16

Further Information