Langworthy Medical Practice

Langworthy Medical Practice
Child Online Registration

 

Please do NOT use this form to update your address or contact details.

Please fill in your details and click Submit when complete. * = compulsory

Please only complete this registration form once. If you have previously submitted this form
at any time please do not do so again unless advised by the Medical Practice to do so.

* Has your child ever registered
with this practice before?
* Child's title:  
Please enter all your first names in full
 If you don't know your NHS number it's very important that you fill in part 1 and 2 below
* Child's gender at birth:  
 
CHILD'S HOME ADDRESS
 
 
*  
*  
*

Parent/Carer Details (should be child's Next of kin):
Is the parent/carer registered at Langworthy Medical Practice?   
Carer's full name:
Relationship to child:
Enter your own telephone number. Preferably your mobile number

Enter your e-mail address
Confirm your e-mail address
Do you give consent for us to CONTACT YOU via text message or email?
* Text/SMS:
                 * Email: 
You are giving permission for us to send you appointment reminders, information regarding  your health care and clinic updates.
How would you prefer to be contacted?
   
 
* Parent/Carer signature:
Please draw your unique signature in the box
   
Child's Health Questionnaire
 
* Is your child a Young Carer?      

IMMUNISATIONS
It is important that we know the status of your children's immunisations. Has your child
ever had the following vaccinations? Alternatively, please attach them below.
BCG:   1st Pneumococcal:
HPV (girls):   2nd Pneumococcal:
1st Diptheria/Tetanus/Pertussis/Polio/HIB:   Pneumococcal booster:
2nd  Diptheria/Tetanus/Pertussis/Polio/HIB:   Meningitis C:
3rd Diptheria/Tetanus/Pertussis/HIB:   Meningitis Booster:
Diptheria/Tetanus/Pertussis/Polio Booster:   1st MMR vaccine:
1st Rotavirus:   2nd MMR vaccine:
2nd Rotavirus:      
If you have a list of your child's immunisations, please attach it here:
Your child's registration may not be completed without this information.

 cm  kg
 
Does your child have any of the following MEDICAL CONDITIONS?
 
 
 
 
Any other current and past MEDICAL /
SURGICAL / MENTAL HEALTH ISSUES
 
Please specify name of condition and
year of diagnosis (if known):
   
 
   
Please give details of any DISABILITY:
Are you Registered BLIND or DEAF?   
Please indicate if you require any of the following Communication Services:
           

Interpreter required?   
Are you currently a Refugee or Seeking Asylum in the UK?

* Is your child known to Children’s Services/Social Services?   
If Yes, what is the name of your Social Worker?

* Summary Care Records
Summary Care Record (SCR) - this is an electronic record which contains information about the medicines you take,
allergies you suffer from and any bad reactions to medicines you have had. Having this information stored in one place
makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed.
  
 
* Important Information
It is practice policy to share information that is recorded on your clinical record with other clinical staff that you are under
the care of to ensure the best care is provided to you. For further information please ask for an information leaflet
or visit www.nhscarerecords.nhs.uk/carerecords.
Your record will be automatically setup to be shared with the other Health Care organisations. These organisations
will only be able to view your shared record if they are actually providing you with care. However, you have the right
to ask your GP to disable this function or restrict access to specific elements of your record.  This will mean that
the information recorded by your GP will not be visible at any other care setting
Do you consent for us to share your medical records with other medical service
you may be using i.e. District Nurse Teams, Podiatry or Dieticians?
  
 
ONLINE ACCESS REGISTRATION
Would you like to have access to the following online services?
Booking appointments:     
Request repeat prescriptions:  
 
Organ Donor Registration
If you are interested in becoming an organ donor, please click this link
to go to the organ donor registration page.
 
Blood Donor Registration
If you are interested in becoming an blood donor, please click this link
to go to the blood donor registration page.
 
Please read the CampusDoctor Privacy Notice.
The information you are submitting will be sent encrypted to the medical practice over the Internet, which still isn't 100% secure.
If you are worried about this you can instead obtain a form from the medical practice that can be filled in and delivered by hand.
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