Registration Form Child - Sidney House & The Laurels

First Name *

Surname *

Current address (if different from child’s)

Contact details (if different from above)

What is your relationship to the child: (ie Mother, father - specify) *

Consent to be contacted by text message *

Yes No

Does the child have contact with the father

Has your child have contact with their father?

Yes No

First Name

Surname

Current address (if different to child’s)

Contact details (if different to child)

Other Information

Communication Needs

The Accessible Information Standard aims to ensure patients and/or their carers who have a disability or sensory loss can receive, access and understand information in a suitable format e.g. large print, braille, email or from a British Sign Language interpreter. Individuals most likely to be affected by the Standard are those who have sight and/or hearing loss and people with a learning disability (this list is not exhaustive)

Does the child/young adult have specific communication needs?

Yes No

Tell us about your child's/young adult VISION - NORMAL / IMPAIRED VISION / REGISTERED PARTIALLY SIGHTED / REGISTERED BLIND / WEARS GLASSES / WEARS CONTACT LENSES

Does your child /young adult wear hearing aids?

Yes No

Does the child/young adult need an interpreter?

Yes No

Does the child/young adult have Learning Disability?

Yes No

What other communication support might they need?

NHS SUMMARY CARE RECORD (SCR)

The SCR was introduced many years ago to help deliver better and safer healthcare. It contains basic information about and allergies you may have, unexpected reactions to medications and any prescriptions you have recently received. The intention is to allow Hospital A&E departments and Out of Hours health services to give you safe, timely and effective treatment. Over time, health professionals treating you may add details about your health to the SCR with your consent.

Please tick one option for the content of your SCR *

I consent for medication, allergies and adverse reactions only

I consent for medication, allergies and adverse reactions and additional information

I DO NOT want a Summary Care Record and I understand the risks involved with this decision.

Sharing Your Health Record

With the development of information technology, the NHS will increasingly be sharing key information from your GP Medical Record with Out of Hours GP Services, Hospital A&E Units, Community Hospitals, Community Nurses, all of who may be looking after you at various points in your life. Sharing your information can improve the quality and safety of care you receive and in some cases can be vital in making life-saving decisions about your treatment.

Do you consent to the sharing of data by your GP Practice with other NHS organisations that may care for you? *

Yes No

Do you consent to the GP Practice viewing data that is recorded at other NHS organisations and care services that care for you? *

Yes No

Registration form for child or young person

Further Information