New patient registration (child under 13)

Named GP

All patients registering at Mere Surgery will be allocated a named General Practitioner depending on their surname.

Patients with a surname beginning with A-K will be allocated under Dr Halsey and patients with a surname beginning with L-Z will be allocated under Dr King.

Patients are however free to see any doctor of their choice for each consultation although we would encourage you to see the same doctor for the duration of each problem to ensure continuity of care.

Patient’s Details

Please specify:

Surname: *

First Name(s) *

Preferred Name:

Previous Surnames:

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Gender *

Male

Female

Indeterminate

NHS Number:

Town and Country of birth: *

Home Address: *

Postcode: *

How long has this child lived at this address?

Less than 6 months

More than 6 months

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

If registering a child under 5:

I wish the child above to be registered with Mere Surgery for Child Health Survelliance.

Previous Address Details

Has this child ever been registered with a GP in the UK? *

Yes

No

Child’s Previous address in UK:

Please include postcode.

Name and address of previous GP:

If you are from abroad

Date child came to live in the UK:

Please use this date format: DD/MM/YYYY.

If previously a resident in the UK, please specify the date the child left:

Please use this date format: DD/MM/YYYY.

Child’s first UK home address when registered with a GP:

Child’s Parent/Guardian Details

Name of Mother/Father/Guardian: *

Relationship to child: *

Date of Birth: *

Address of Mother/Father/Guardian: *

Mobile:

Home Telephone:

Work Telephone:

Do you give us permission to discuss this child’s full medical records with the above person? *

Yes

No

Name of Mother/Father/Guardian:

Relationship to child:

Date of Birth:

Address of Mother/Father/Guardian:

Mobile:

Home Telephone:

Work Telephone:

Do you give us permission to discuss this child’s full medical records with the above person?

Yes

No

Allergies

Does the child have any allergies? *

Yes

No

Please specify what they are allergic to, what happens and when they had their first reaction:

Child’s Nationality

Please state:

Child’s Health

Type of Birth if under 5 ( Normal, Forceps, Caesarean)

Birth Weight if under 5:

Feeding if under 5 (Breast or Bottlefed):

Does the child take regular medication? *

Yes

No

Please specify:

Does the child have any long-term illness, health problem or disability? *

Yes

No

Please specify:

Please make an appointment for a new patient health check.

Any other important family illnesses:

Please state the family member to which illness relates to:

Child’s Language

Child’s main spoken language (one only): *

Does the child have any problems reading English? (school age children only) *

No problems

Some problems

A lot of problems

Does the child have any problems speaking English? *

No problems

Some problems

A lot of problems

If English is not the child’s main spoken language or yours, do they or you need an interpreter (someone to help with language) when they visit the doctor? *

Yes

No

Child’s Immunisation History

Please give details of any immunisations this child has received and the date given and the clinic where given: *

Please include dates.

Child’s School or Nursery

Name of school/nursery:

Address of school/nursery:

Health Professionals

Does the child have contact with any of the following?

A hospital specialist

A health visitor

A social worker

Any other health professionals

if so, please can you tell us their names

Hospital specialist name:

Health visitor name:

Social worker name:

Any other health professionals details:

Has the child ever been under a Child Protection Plan? *

Yes

No

Child’s Brother/Sisters/Siblings

Brother/Sisters/Siblings (Please give details of Name and Date of Birth):

Data Sharing Consent Choices

To maintain continuity of clinical care, we upload certain medical information so that it is available to other healthcare organisations (eg Emergency Departments).

Details of how we share your information are found in the Privacy Notice available on our website or ask reception for a copy.

If you wish to opt out information is available at www.nhs.uk or ask at reception.

Where you have provided information on how to contact you, can you confirm you are happy for Mere Surgery to contact you by the following:

By SMS text messaging: *

Yes

No

Reminders for appointments, invitations to book into clinics and updating information about the surgery.

By email: *

Yes

No

My Data Matters

If you do not wish the NHS to share data from this child’s health records for the purposes of research and planning, please follow this link to opt out.

Summary Care Records (SCR)

These are an electronic record of important patient information, created from GP medical records. They can be seen and used bu authorised staff only; in other areas of the health and care system involved in the patients care.

To Opt Out, visit www.digital.nhs.uk/scr

Dispensing

Dispensing – If you live more than 1 mile in a straight line from the nearest pharmacy

Child lives more than 1 mile in a straight line from the nearest pharmacy and would like to collect dispensed medications from the dispensary at Mere Surgery

Non-Dispensing – If you live less than 1 mile in a straight line from the nearest pharmacy

I would this child’s prescriptions to be sent to Mere Surgery pharmacy for collection

I would this child’s prescriptions to be sent to the following pharmacy for collection

Not sure what your closest pharmacy is?

Use the NHS Find a Pharmacy tool.

Pharmacy Name: *

Pharmacy Address: *

Pharmacy Postcode: *

NHS Organ Donor registration

For more information on organ donation please visit: www.organdonation.nhs.uk

Submission

Signature on behalf of patient: *

Relationship to Patient: *

Date:

To help complete your registration, please upload proof of identity, this should include photographic ID, proof of address and an image of you.

Maximum upload size: 67.11MB

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New patient registration (child under 13)

Named GP

Patient’s Details

Previous Address Details

If you are from abroad

Child’s Parent/Guardian Details

Allergies

Child’s Nationality

Child’s Health

Child’s Language

Child’s Immunisation History

Child’s School or Nursery

Health Professionals

Child’s Brother/Sisters/Siblings

Data Sharing Consent Choices

My Data Matters

Summary Care Records (SCR)

Dispensing

Dispensing – If you live more than 1 mile in a straight line from the nearest pharmacy

Non-Dispensing – If you live less than 1 mile in a straight line from the nearest pharmacy

NHS Organ Donor registration

Submission