Summer Fields School registration form

Summer Fields School

Last Updated: 27/06/2023

Basic Information

Title

Email address of parent/guardian

Surname: *

First Name(s): *

Previous Surname:

Sex *

Male

Female

Date Of Birth (dd/mm/yyyy) *

NHS Number (if previously registered with NHS):

Birth Town: *

Birth Country: *

Telephone:

Medical Records

Please help us to trace your previous medical records by providing the following information. If you are from abroad please move to the next section

Your Previous Address In The UK

Name of previous GP while at your previous address

Address of that Doctor

Medical Records (abroad)

If you are from abroad please provide the following information:

Your first UK address where registered with a GP

Date you first came to live in UK

Signature

Signature Of Patient

Signature On Behalf Of Patient

Summary Care Record

Summary Care Record (SCR) – used nationally across England

The SCR is a national database intended to help patient care, particularly in emergencies. It contains registration details (name, address, date of birth, NHS number etc) and a list of prescribed medication and allergies. It is useful for an Accident & Emergency department to check for allergies or drug interactions, to improve the treatment they can provide for you. It is also possible to ask for a more detailed SCR containing significant diagnoses, referrals, vaccinations, care plans or other details. Your permission will be checked each time, unless there is a special factor such as being unconscious or otherwise unable to consent. For further information see https://digital.nhs.uk/services/summary-care-records-scr

Your choice for Summary Care Record *

I would like to have a SCR detailing medication, allergies and adverse reactions ONLY

I would like to have a SCR detailing medication, allergies and adverse reactions AND ADDITION INFORMATION (such as diagnoses, care plans and anything else considered important)

I do NOT wish to have any of my medical details recorded in the SCR

Oxfordshire Summary Care

The Oxfordshire Care Summary and the Out – Hours GP records sharing system

Your patient record is held securely and confidentially on an electronic system controlled by your GP Surgery. Your information can be viewed if you need treatment in another NHS healthcare setting, such as an Emergency Department, Out of Hours, GP, Minor Injury Unit or College Nurse (if applicable). The professionals treating you can give you safer care if medical information from your GP Surgery is available to them. In all these cases, your information will be viewed only by authorised healthcare professionals directly involved in your care. You will be asked permission before the information is accessed unless the health professional is unable to ask you and there is an important clinical reason for accessing it.

Please select one option below *

I agree to opt IN

I do NOT agree to opt in

Important

It is important to complete this information as your new practice cannot make a decision for you. Without your direction, we cannot guarantee that your wishes will be met, even if you have previously made a similar choice in another practice. If the person signing below is not the patient, please also enter the signatory’s name and relationship to the patient, e.g. PARENT, GUARDIAN, ATTORNEY

Full Name

Relationship to patient

Signature

Ethnicity & Language

Medical Information

Please list any illness/accidents/operations (please include any physical and nervous conditions and any important disabilities). Please include year of diagnosis.

Is your child under medical care of any sort? If yes, please describe

Does your child take any medication? If yes, please describe along with dose

Routine childhood immunisations

Usually given around 2 months

1st DTAP/IPV/HIB (diphtheria, tetanus, pertussis, polio and HIB)

Hepatitis B

Men B (meningococcal B)

Rotavirus

PCV (pneumococcal)

Routine childhood immunisations

Usually given around 3 months

2nd DTAP/IPV/HIB (diphtheria, tetanus, pertussis, polio and HIB)

PCV (pneumococcal)

Hepatitis B

Rotavirus

Routine childhood immunisations

Usually given around 4 months

3rd DTAP/IPV/HIB (diphtheria, tetanus, pertussis, polio and HIB)

Hepatitis B

Men B (meningococcal B)

PCV (pneumococcal)

Routine childhood immunisations

Usually given around 12 - 13 months

HIB/MEN C

1st MMR (measles, mumps and rubella)

PCV (pneumococcal booster)

Men B (meningococcal B)

Routine childhood immunisations

2nd MMR (measles, mumps and rubella)

Routine childhood immunisations

Usually given around 3yrs 4 months

4th pre school booster DTAP/IPV (diphtheria, tetanus, pertussis and polio)

Non-routine vaccines

BCG

Meningitis C

HIB Booster (Haemophilus Influenza B)

Any other vaccines - please list type along with date given

Signature

Signature *

Full name of person signing form *

Relationship to patient *

Parent

Guardian

Thank you

Thank you for completing this registration form. When your form is complete please press the submit button. Your registration form will be sent to the Practice.

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Summer Fields School registration form

Further Information