New baby patient registration

Baby’s Details

Title: *

Mr

Miss

Ms

Other

Please specify:

Family Name/Surname: *

Given Name(s)/First Name(s): *

Gender: *

Male

Female

Town and Country of Birth:

Current Manchester address: *

Postcode:

Home telephone number:

NHS Number:

Ethnicity and Religion

Other White please state:

Other Mixed please state:

Other Asian please state:

Other Black please state:

Any Other please state:

Please specify:

Main spoken language of parent:

Main reading language of parent:

Summary Care Record

Your GP surgery needs permission to share important information from your GP record. This is called a summary care record (SCR). The SCR can only be shared with health and care staff across England who are providing you with direct care. It gives them access to vital information from your child’s GP record.

Your options are:

a basic summary care record that includes details of your child’s medicines, allergies and adverse reactions only
an enhanced summary care record that includes details of your child’s medicines, allergies, adverse reactions and any significant illnesses and health problems, operations and vaccinations
opting out of a summary care record meaning you do not want any information shared with other healthcare professionals involved in your child’s care

What is your choice for the child’s summary care record?

Basic summary care record

Enhanced summary care record

Opt out of a summary care record

Mother’s Details

Mother’s Full Name: *

Mother’s mobile telephone:

Mother’s work telephone:

Email Address: *

Signed: *

Please put the name of parent/guardian.

Date:

Next of Kin / Emergency Contact

Who is next of kin/the emergency contact for the child?

Mother

Mother and other

Other

First Name:

Relationship to baby:

Phone Number:

Next of Kin address:

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Baby’s Details

Ethnicity and Religion

Summary Care Record

Mother’s Details

Next of Kin / Emergency Contact