Child New Patient Questionnaire

To register at the Junction Surgery we ask that you complete this form along with a 'Family doctor services registration (GMS1)' form.

Once completed we will need to see proof of identification and so ask that you attend one of our surgeries with this.

Your registration will not be completed until we have verified your identity and have received completed forms.

Last Updated: 05/09/2023

  • Proof of Identity and Address Provided

    Identity Document Type

  • About you

    Date of Birth
    For example, 15 3 1984

  • Ethnicity and main spoken language

    Since 1 April 2006 the Department of Health has asked that we record the ethnic origin of all newly registered patients. In certain clinical circumstances this information can be of help to doctors in providing you with more appropriate care.

    Ethnic Group
    Do you need an interpreter?

  • Address and contact details

    Do you consent to receiving appointment reminders and other information via text message?
    Online services allow you to book appointments, order prescriptions, and view records online. Would you like us to send an online services registration form to your email address?

  • Next of Kin

  • Previous address and doctor

    Date of entry into the United Kingdom (if applicable) (optional)
    For example, 15 3 1984

  • Additional information

    Do you have any information or communication needs that you want us to know about?
    Are you an asylum seeker?

  • Carers

    Are you a carer?
    Do you have a carer?

  • Other important things to know

    Share for You

    As of December 2018 all GP records will be available to view, to other health and social care professionals outside the GP surgery directly involved in your care. For more information please visit: hmrshareforyou.nhs.uk

     

    Named GP

    At the Junction Surgery, all of our patients have been registered to a named GP partner and they will be the GP with this responsibility. If you do not know who your registered GP is, please feel free to contact the surgery and a receptionist will be happy to inform you. You may continue to request to see any of our GPs for your appointments and so you should see no change in the day to day running of the practice or your care.

  • Medical Information

    Have you ever suffered from? (tick as appropriate) (optional)
    How often do you exercise each week?
    Would you like info on healthy exercising? (optional)
    Are you allergic to any foods or medicines?

  • Family History

  • Supplemental Registration For for Children under 18

    When a child (under 18 years) is registered to the practice, we are required to request all of the following information.

  • Adults living at the same address as the child

    The practice must request the names of any adults (over 18s) living at the same address as the child. Please give these below and indicate if they have legal parental responsibility for the child.

    Does the above have parental responsibility?
    Does the above have parental responsibility? (optional)
    Does the above have parental responsibility? (optional)

  • Summary Care Record preferences form

    Information about Summary Care Records

    You can find information about Summary Care Records using the below links:

    SCR - Information for patients

    NHS Care Records

    NHS Care Records Services Information Line on 0300 123 3020

    Opting out

    If you wish to opt out of having a summary care record, please complete the linked form and send to us.

    Summary Care Record Opt Out Form

    Please be advised that we will create your Summary Care Record following your registration with this practice unless you express a preference otherwise

  • Signature

    Date
    For example, 15 3 1984
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