Online Child Registration Form (Under 16 years old)

For children under the age of 16 only (young persons aged 16 and over to complete an Adult Registration Form) Please complete clearly all relevant sections of this registration form.

When completing this form make sure you have with you your photo ID, health card, proof of address and the child’s red book/immunisations history record. These documents will have to be uploaded before submitting this registration.

1. Patient Information

Your Name

Title Given Name Family Name

Known as Optional

Date of birth

MM slash DD slash YYYY

Resident in Jersey since

MM slash DD slash YYYY

Jersey Social Security Number

Does parent/legal guardian hold a Green Health Card?

Patients need a health card to get a subsidy when visiting General Practitioners (GPs). Health cards are issued if a resident has lived in Jersey for at least 6 months and have paid Social Security contributions. For the first 6 months after arriving in Jersey, new residents don’t hold a health card and will have to pay the full cost should they need to visit a GP or another health care provider.

Gender Identity

Ethnicity (a)

Ethnicity (b)

First Language (if not English) Optional

Reason for registering with the Practice

Transferring from another Jersey GP Practice

Re-registering with GP Practice

New resident in Jersey

NOTE: If you are a new resident in Jersey, for the first 6 months patients are charged the full cost should they need to visit a GP or another health care provider

2. Home Address and Parent/Legal Guardian Information

At least one Parent/Legal Guardian must also be primary registered with the practice

Current home address

House Name / Flat Name Number & Street Parish / Town Postcode

PRIMARY Parent/Legal Guardian Info

Parent/Legal Guardian

Title Given Name Family Name

Date of birth

MM slash DD slash YYYY

Relationship to the child

Mobile Tel No.

Home Tel No. Optional

Work Tel No. Optional

Consent to receive SMS

Personal Email Address

Email Address Confirm Email Address

Consent to receive emails

SECONDARY Parent/Legal Guardian Info

Parent/Legal Guardian

Title Optional Given Name Optional Family Name Optional

Date of birth Optional

MM slash DD slash YYYY

Relationship to the child Optional

Mobile Tel No. Optional

Home Tel No. Optional

Work Tel No. Optional

Consent to receive SMS Optional

Personal Email Address

Email Address Optional Confirm Email Address Optional

Consent to receive emails Optional

3. Medical History

Allergies: Does the child have any known allergies or do they have any adverse reaction to drugs or medication

If YES, please provide details: Optional

Medication: Does the child currently take any medication?

If YES, please provide details: Optional

Has child suffered from any significant ongoing medical problems or had any serious illness/operations in the past

If YES, please provide details: Optional

4. Child Health Check and Immunisation History

IMPORTANT: Please provide copy of the ‘Red Book’ or Child Immunisation History Record

Tick if this child has had any of the following:

6 Week Baby Check with GP

First Primary Vaccinations (Aged 8 weeks -13 months)

Second Primary Vaccinations (Pre-School Aged 3 years, 4months)

Year 8 School Vaccinations (Aged 12-13)

Year 9 School Vaccinations (Aged 13-14)

None

Any vaccinations declined?

If YES, please provide details: Optional

Child's Health Visitor Optional

Child's Current School Optional

Please provide to the practice any information regarding any other vaccinations given to this child Optional

5. Private Medical Insurance

The Parent/Guardian is responsible for making all claims with the insurer. Payment for services must be done by the patient and ask insurer for reimburse

Insurance Provider Optional

6. Previous/Existing GP Information

This will be used to request previous medical record information

GP Name Optional

Name of GP Practice

Tel No. Optional

Reason for transferring

8. Patient Declaration, Confidentiality Agreement, Personal Data Statement and Communication

This declaration should be signed ‘for and on behalf of’ the child named on this registration form by the Parent/Legal Guardian as given in section 2

Personal Information (Data Protection and Patient Privacy):

I understand that the information collected on this application form will be used by First Medical Ltd (hereafter the ‘Practice’) for the purposes of healthcare related services and practice administration.

I understand that personal information First Medical hold about me is processed for the purposes of ‘Employment and Social Fields’ (Article 8) ‘Medical Purposes’ (Article 15) and ‘Public Health’ (Article 16) of the Data Protection (Jersey) Law 2018.

I understand that this may require your personal data including, relevant details of your medical history, to be shared with other approved healthcare providers for the purpose of referrals and for other lawful purposes related to the Practice procedures.

Further information on how we hold and process your data can be found in our Data Protection and Patient Privacy Policy.

General Practice Central Services (GPCS):

I understand that all Jersey GP Practices and other approved healthcare service providers, such as the out-of-hours doctors, use a central medical records system known as EMIS.

I understand this allows access to a ‘shared medical record’ to ensure that the provider or clinician has immediate up-to-date and accurate information about your health and any current treatment you may be having.

I understand that I have the right to ‘opt out’ of sharing some or all of my medical records. I can ask the practice for more information and if appropriate an Opt-in/Out Form for completion.

All approved healthcare service providers with authorised access to GPCS have signed strict confidentiality agreements which are bound by the Data Protection (Jersey) Law 2018.

Children Aged 13-16

I understand that The Data Protection (Jersey) Law 2018 provides that a child aged between 13 and 16 has their own right to consent and data confidentiality privacy.

I understand that a child aged between 13 and 16 has “sufficient understanding and intelligence to enable them to understand fully what is proposed” (known as Gillick Competence), then they may be competent to give consent for themselves.

I understand that Further information can be found in the practice Data Protection and Patient Privacy Policy.

Your Declaration to us:

• I confirm that all the information I have given in this registration form is accurate to the best of my knowledge.

• I understand that the Practice has the right to accept or decline my registration application at any time.

• I understand that by attending a consultation with a GP or other healthcare professional of the Practice, I accept the Practice terms of service and fee schedule issued and displayed in the Practice premises and as amended from time to time.

• I hereby agree to pay any incurred service fees from the Practice at the time of attendance or treatment.

• I expressly consent that on registration or prior to accepting any credit arrangement from the Practice, where appropriate a credit reference check may be taken with an authorised credit reference agency and/or my previous medical practice(s).

• I give my express permission for the Practice to request information including my medical records from my previously registered GP and I agree to reimburse the Practice for any charges and disbursements incurred relating thereto for the Practice being provided with such information.

• I understand it is my sole responsibility to advise the Practice in writing of any changes made in respect of my personal information.

Parent/Legal Guardian Signature

Parent/Legal Guardian Print Name

Child's Name

Registration Request Date

MM slash DD slash YYYY

Parent/Guardian Photo ID

Max. file size: 1 GB.

Valid passport, driving license or identity card

Parent/Guardian Proof of address

Max. file size: 1 GB.

Utility bill dated within 3 months; this document must have your name

Parent/Guardian Green Health Card

Max. file size: 1 GB.

if you don’t hold a green card, please upload copy of your Social Security Card. However, without a green health card you will be charged full price until the card is presented

Red Book or Immunisation Record History

Max. file size: 1 GB.

Comments Optional

This field is for validation purposes and should be left unchanged.