New patient Additional Information - Thornbury Road Centre for Health

To ensure we can provide you with the best possible care, we would like to gather a bit more information.

This additional form will help healthcare professionals get a better understanding of your needs. Please take a moment to fill in the form below.

Name

First Last

Date of birth

Day

Month

Year

NHS Number (if known) Optional

Contact Number

Enter Email Confirm Email

We will use your mobile number to send appointment reminders and health promotion details.

I do wish to receive these messages

I do not wish to receive these messages

Click here for our Text message/email OPT-IN information.

How would you prefer us to contact you?

Letter

SMS (text)

Phone

Are you completing this form for a child under 16 years old?

Yes

Armed Forces

Please indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas:

Regular

Reservist

Veteran

Family Member (Spouse, Civil Partner, Service Child)

I have NOT serviced the armed forces

Please note that these questions are optional, and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority or service charities services.

Are you homeless?

Yes

What is your current immigration status?

Asylum Seeker

Failed Asylum Seeker

Are you housebound?

Yes

Further Information

Do you have a ‘Living Will’ or ‘Advanced Directive’?

Yes

An advance decision (sometimes known as an advance decision to refuse treatment, an ADRT, or a living will) is a decision you can make now to refuse a specific type of treatment at some time in the future.

Have you nominated someone who has Power of Attorney or been assigned a Personal Welfare Deputy?

Yes

About You (Parent or Guardian)

Name of adult registering the child

First Last

Relationship to Child

Are you registered or registering at this practice?

Yes

Who has legal parental responsibility?

Do you consent to be contacted by SMS?

Yes

Do you consent to be contacted by email?

Yes

It would be helpful to get your child’s birth certificate as this helps to show who may hold parental responsibility do please upload the birth certificate below. Optional

Max. file size: 50 MB.

Upload vaccination here

Next of Kin / Name of person(s) with legal parental responsibility

Name

First Last

Gender

Female

Male

Other

Please list other residents at your home. Are they registered with us?

Please state name, relationship to child & if they are registered with us.

Private Caring Arrangements

Is your child being looked after by a friend, neighbour in their home?

Yes

Is someone looking after your child at home?

Yes

Carer’s Name

First Optional Last Optional

Carer’s Contact Number

Carer’s Address

Street Address Address Line 2 City Postcode

Relationship to you

Please tick if your child is currently

Homeless

A refugee

An asylum seeker

None of the above

Is your child currently housebound?

Yes

Is the child a ‘child looked after’ under the care of the local authority?

Yes

Is your child or family currently involved with Children’s Social services or have they ever been known to Children’s Social services or the safeguarding team?

Yes

Your Child’s Background Information. Due to government policy, we are obliged to ask you the following:

Do you need an interpreter?

Yes

Please state below

Your Child’s Medical Background

Please provide details of any medication your child takes (including the contraceptive pill):

Please state the name of medication, dosage & frequency

Immunisation History

For children under 16, we require a copy of their vaccination records in order to complete their registration.

For children under 16, we require a copy of their vaccination records in order to complete their registration. Optional

Max. file size: 50 MB.

If your child has had vaccinations abroad or privately, you will need to send us a copy of their vaccination record so please upload here.

Parent/Guardian permission given

Permission given for someone other than a Parent/Guardian to accompany your child to an appointment?

Yes

E.g. Grandparent, Nanny, childminder

Online Services – NHS App

To book and manage appointments, order your prescriptions and view your medical records please download the NHS App, or open the NHS website in a web browser.

The practice often communicates with patients via the NHS app so once is all set please turn on your notifications to receive updates from us.

To set up and log in to your NHS account so please visit to get started. www.nhs.uk/nhs-app/about-the-nhs-app

Your Medical Information – Sharing Your Data

Under the General Data Protection Regulations (GDPR), we have a responsibility to keep your medical records confidential. We need your consent to share this with other authorised health professionals involved in your care or in planning your care. You can find more information on the website at www.nhs.uk/your-nhs-data-matters

Please see the privacy notice on our website for more information on how your data is held and used by the practice.

The NHS wants to make sure you and your family has the best care now and in the future. Your health and adult social care information supports your individual care. It also helps us to research, plan and improve health and care services in England.

There are very strict rules on how this data can and cannot be used, and you have clear data rights. We are committed to keeping patient information sate and will always be clear on how it is used.

You can choose whether or not your confidential patient information is used tor research and planning.

If you do not wish your information to be used in this way please opt-out by visiting NHS: Your Data Matters or by calling 0300 303 5678. The practice is unable to record this for you.

Sharing In

Do you consent to the viewing of data by this organisation that is recorded at other care services that may care for the patient where the patient where the patient has agreed to make the data sharable?

I consent

I do not consent

Sharing Out

Do you consent to the sharing of data recorded here with any other organisations that may care for you?

Yes – share data with other organisations

No – do not share any data recorded here

Thank you for completing this form

Please see our practice website for further information about our team/services.