Dr Barnfield & Partners
Lordshill District Centre
Southampton
S016 8HY

Tel: 02380 738144

Providing NHS Services
Armed Forces veteran friendly accredited GP practice

New Patient Registration Form for Children

Please answer all questions as fully as possible. Questions marked * must be completed.

New Patient Registration – Child

Patient’s Details

Please complete text boxes as accurately as possible and select options where appropriate.
Please use day/month/year format. e.g. 04/10/59
Country of birth *
Enter Email
Confirm Email
Can we contact you by text?
Can we contact you by email?
Please use day/month/year format. e.g. 04/10/94

Patient’s Previous Details

Please help us trace your previous medical records by providing the following information.
Please include postcode

Parent/Guardian Details

Are you next of kin?

Parent/Guardian Details

Are you their next of kin?

Personal Medical History

(Not applicable to looked after children)
(Under 5 only e.g normal, forceps, caesarean)
(Under 5 only breast or bottle)

Allergies

Does your child have any allergies?

Health

Does your child take regular medication?
Does your child have any long-term illness, health problem or disability?

Electronic Prescribing

The Electronic Prescription Service (EPS) sends electronic prescriptions from GP practices to pharmacies. Eventually EPS will remove the need for most paper prescriptions.

Would you like to nominate a pharmacy for electronic prescribing? *

Language

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

Ethinicity

Immunisation History

Please include dates

Health Professionals

Does your child have contact with any of the following?
Has your child ever been under a Child Protection Plan?
Is this child in foster care?

My Data Matters

If you do NOT wish the NHS to share data from your childs health records for the purposes of research and planning, please opt out on the NHS website.

Summary Care Record (SCR)

This is an electronic record of important patient information, created from GP medical records. They can be seen and used by 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

NHS Organ Donor Registration

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

What happens to my Childs information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

I certify that the information I have provided is correct and consent to my Childs personal and medical information being used as stated above.

Privacy Policy

This form collects your childs name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.