Title


 
Surname *

 
First Name(s) *

 
Middle Name(s)

 
Previous Surname

 
Date of Birth *

 
NHS Number

 
Town and Country of Birth *

 
Address *

You must be Lambeth resident to be able to register with The Exchange Surgery
 
Post Code *

 
Telephone Number *

 
Alternative telephone number

 
Your previous address in UK, including post code *

 
Name and address of previous Doctor or GP surgery *

 
If you are from abroad

Provide the date when you first came to UK (be  as exact as possible, even if this is an estimation)
 
Is anyone from your household already registered at this practice? Please provide their names and date of birth:

 
Type of Birth

If new born or under 1 year old

 
Has your child ever suffered from any important medical illness, operation or admission to hospital? If so, please enter details below (Conditions, when diagnosed and if still ongoing)

 
Have any close relatives (father, mother, sister, brother only) ever suffered from:


 
List of current medication (name and dosage)

 
The ELECTRONIC PRESCRIPTION SERVICE (EPS)  is a NHS Service. It gives the chance to change how your GP sends your prescription to the place you choose to get your medicines or appliances from. Your prescription will be sent electronically to the pharmacy of your choice. This means you will not need to come into the surgery to collect your prescription as it will be prepared and ready for collection at your chosen pharmacy.

 
Your chosen pharmacy

 
Allergies

Please list any allergies your child have to any drugs/ medication
 
Immunisations

Please provide details of your child immunisations - if possible please give your Red Book to the Reception to photocopy
 
BCG

     
 
1st Immunisations at 2 months of age

1st Diphtheria, tetanus, pertussis (whooping cough), polio and Hib (DTaP/IPV/Hib)
1st Pneumococcal (PCV)
1st Meningococcal group B (Men B)
1st Rotavarius
     
 
2nd Immunisations at 3 months of age

2nd Diphtheria, tetanus, pertussis, polio and Hib (DTaP/IPV/Hib)
2nd Rotavarius
     
 
3rd Immunisations

3rd Diphtheria, tetanus, pertussis, polio and Hib
2nd Men B
2nd Pneumococcal
     
 
One year old immunisations

Hib and MenC
Pneumococcal
Men B
     
 
1st MMR (Measles, mumps and rubella) *

     
 
Pre-school Booster (Three years four months old)

Diphtheria, tetanus, pertussis and polio
     
 
2nd MMR (Measles, mumps and rubella) *

     
 
Human papillomavirus

Girls aged 12 and 13
     
 
Immunisations at Fourteen Years old

Tetanus, diphtheria and polico
Meningococcal ACWY
     
 
Comments

 
Religion

 
Main spoken language

 
Do you require an interpreter

     
 
Name of Parent/ Guardian and relationship to the child *

You need to have a parental responsibility and be also registered at the practice. For safeguarding reasons, please bring your child birth certificate and your passport to verify the child identity and your parental rights.
 
Name of other parent/guardian and relationship

 
Is anyone else likely to bring your child to the surgery? If yes, please state their name and relationship

 
Is your child subject to a child protection plan

     
 
Name and address of school your child attends

 
There is a new 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. Storing information in one place makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed.This information could make a difference to how a doctor decides to care for you, for example which medicines they choose to prescribe for you. You can find out more on www.nhscarerecords.nhs.uk

 
Summary Care records - would you like: *


 
Sharing with other services We may need to share your medical information with other organisations involved in the delivery of your care e.g. Podiatry or District Nursing. We will not share identifiable information with anyone that isn’t involved in your care unless legally required to.   To maintain continuity of clinical care, we upload certain medical information so that it is available to other healthcare organisations (eg Emergency Departments).  Please see our website or ask receptionist for a leaflet which details what part of your record is extracted and how it is used to help other NHS organisations.    If you wish to Opt out, please speak to receptionist.

 
New patients are currently being assigned to one of our partners as the usual named doctor. You can change your usual doctor if you wish at any time, by asking at reception or e-mailing us. Do you want to be allocated to any specific doctor?

 
You can now book appointments online, order repeat prescriptions, message the doctor and access most of your medical records online using www.patient-access.co.uk
If would like the access, you need to bring your photo ID and proof of address and fill out an application form. The receptionist will issue login details once we confirm your registration.
Please note, once your child turns 11 years old, the online access will be revoked. You can re-apply and the access will be assessed by a doctor on case by case basis

 
Would you like the online access for your child

     
 
Signature of Parent/Guardian

I confirm that the information I have provided is true to the best of my knowledge
 
Date completed

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