Pembroke Surgery

New Patient Registration Form–New Births

Please complete this confidential questionnaire in BLOCK CAPITALS and tick the boxes as appropriate. A separate form should be completed for each person registering.

PLEASE NOTE: BY PROVIDING A MOBILE NUMBER AND OR AN E-MAIL ADDRESS ON THIS FORM, YOU ARE GIVING CONSENT FOR THE SURGERY TO CONTACT YOU VIA THESE ROUTES.

Summary Care Records
There is a Central NHS Computer System called the Summary Care Record (SCR). It 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. Access to your Summary Care Record is strictly controlled, the only people who can see the information is the healthcare team currently in charge of your care and they can only access your records via a special card and access pin (like a chip-and-pin card). Healthcare staff will ask your permission every time they need to look at your Summary Care Record, unless they can’t for example because you are unconscious. If they have to do this the decision will be recorded and checked to ensure that the access was appropriate. Further information can be found on our website or by asking a member of staff.
By completing the registration forms at Pembroke Surgery you are giving presumed consent for a Summary Care Record to be created. If however you do not want a Summary Care Record or after further reading you change your mind and wish to opt-out of Summary Care Record, then please see our website or ask at reception for an opt-out form.
Baby’s Full Name: / Date of Birth:
Address and Postcode
NHS Number:
Gender: / Male: / Female:
Mother’s Name: / Date of Birth:
Mr / Mrs / Miss / Ms / Other…….. / Home Number
Email Address: / Mobile Number:
Work Number:
Father’s Name: / Date of Birth:
Mr / Mrs / Miss / Ms / Other…….. / Home Number
Email Address: / Mobile Number:
Work Number:
Your
Religion: / C of E / Catholic / Other Christian (state) / Buddhist / Hindu / Muslim
Sikh / Jewish / Jehovah’s Witness / No religion / Other religion (state)
Your Ethnic Origin:
(select one) / White British / White Irish / White Other
Black Caribbean / Black African / Mixed White/Caribbean / Mixed White/Asian
Indian / Pakistani / Bangladeshi / Other Asian
Background
Other Black
Background / Chinese / Mixed White/Black African / Other Ethnic Group (state)
Your main or 1st language Spoken / Understood:
(select one) / English / Hindi / Gujurati / Urdu / Bengali / Punjabi
Polish / Ukrainian / French / German / Spanish / Other:
(Please specify)

THIS FORM IS TO IDENTIFY IF YOUR CHILD REQUIRES IMMUNISATION

AGAINST TUBERCULOSIS (BCG)

One form to be completed for every child/young person please. To be completed for all young persons aged under 16 years who are registering.

This information WILL NOT be used for any other purpose.

Has your child been immunised against Tuberculosis (BCG)? Please tickYes □ No □

If YES please give the date of immunisation ………………………………………….

Was the child born in the UK?Yes □ No □

If NO please PRINT the country where the child was born

…………………………………………………………………………………………………

Were either of the child’s parents born outside the UK? Please tick Yes □ No □

If YES please PRINT which country the parent/s was/were born in

…………………………………………………………………………………………………

Were any of the child’s grandparents born outside the UK? Please tickYes □ No □

If YES please PRINT which country they were born in

………………………………………………………………………………………………….

Has there been a case of TB in the family in the last 5 years ? Please tickYes □ No □

If YES please confirm if your child was tested for TB at that timeYes □ No □

………………………………………………………………………………………………….