New Patient Registration Child Form

If you need your doctor to dispense medicines and appliances*

I live more than 1.6km in a straight line from the nearest chemist

I would have serious difficulty in getting them from a chemist

To be completed by patients under 16 only

Consent to contact

Please note not being able to send you SMS messages will mean that we won't be able to send you our automatic appointment reminders or to let you know if we've received a test result as this is typically an automatic system.

If you do not want us to have this permission, we can still assist with your medical needs but we need to confirm that you are aware of the impact it may have for your accessibility to the service.

Do you give consent to be contacted by Park Crescent Health Centre using SMS Text messaging? *

Yes No

Do you consent to be contacted by email? *

Yes No

Do you consent to answer phone messages being left on your mobile? *

Yes No

Do you consent to answer phone messages being left on your landline/home telephone? *

Yes No

Contact Preference

Next of Kin

Your next of kin details are requested so we are able to contact a family member or friend if you are needing assistance at the surgery.

Third Party

Your third party contact will be someone who can organise appointments on your behalf, collect prescriptions or fit notes and discuss your care with a clinician. Please be advised that your next of kin and third party are listed separately as they will have different permissions on your medical file.

What is the full name of the person you have chosen to be your third party?

What would you like your third party to have access to?

Collect paperwork on your behalf

Discuss your care with a clinican

Is your third party contact a support/social worker/carer?

If yes, what organisation do they work for?

Do you consent to all staff at this organisation to discuss your care?

Yes No

Nominated Pharmacy

Where would you like us to send your prescriptions?

Record Sharing

This GP practice is able to share your electronic GP record with healthcare professions caring for you elsewhere e.g. in community, hospital or urgent care services. This may help in your care and may save you from needing to remember your medical history and medications. This surgery uses a computer system called SystemOne that allows the sharing of full electronic records across different health services if patient consent is given. There are two ways in which your information can be shared.

Sharing Out - This controls whether your information entered at this surgery can be shared with other NHS services

Sharing In - This controls whether information that has been made shareable at other NHS services can be viewed by the surgery

Access to System On Line and NHS App

This will provide you access to request ongoing medication, to book some clinician appointments and access to prospective Full Record Access.

For children 0-11 Online access will be accessible through parent/guardian details.

Online access is unavailable for patients who are 11-16 years of age

Cookies on the Park Crescent Health Centre website

Further Information