Online Registration Form (new-born to 4 years inclusive) Non-urgent advice: Completing our registration formsPlease complete our online registration Form (GMS1) together with the relevant form for your age group – both forms are required. Step 1 of 2 50% Name First Last Date of birth Day Month Year Mother’s Name First Last Father’s Name First Last Child lives with Mother Father Both Other Please specify Parental Responsibility for child Mother Father Both Other Please specify Nominated Pharmacy for your medication (This is sent electronically)Is your child's first language English? Yes No First language Spoken Interpreter Required? Yes No What is your child's ethnic group?White – BritishWhite – IrishAny Other White backgroundMixed – White & Black CaribbeanMixed – White & Black AfricanMixed – White & AsianAny Other Mixed backgroundAsian or Asian British – IndianAsian or Asian British – PakistaniAsian or Asian British – BangladeshiAny Other Asian BackgroundBlack or Black British – CaribbeanBlack or Black British – AfricanAny Other Black BackgroundChineseOtherPlease specify Consent OptionsAll patients registered at this surgery will automatically have a summary care record created unless they have expressed a specific preference to opt out. To learn more, visit www.nhs.uk/your-nhs-data-matters or call 0300 303 5678 The Practice also has access to the Local Care Record. More information can be found on the website www.chislehurstmedicalpractice.co.uk. If you require further information regarding consent, please visit the Practice Website at www.chislehurstmedicalpractice.co.uk. Online AccessAll patients over 16 will automatically be enrolled for online access to their medical record for appointment booking and requesting medication. If you require access for anyone under 16 or full access to your record please complete the form at the end of this document. The surgery sends text reminders, recalls and urgent messages via text. It is your responsibility to notify us of any changes to your mobile number in writing.If you wish to receive reminder you MUST consent here I consent to receiving SMS text messages from the surgery I do not wish to receive SMS text messages from the surgery Getting in touch is sometimes difficult. Currently we do not leave voice messages without patient consent. Please indicate if you would like us to leave you a brief message. I consent for messages to be left on my mobile voicemail and understand my responsibility as set out below.It is essential that you ensure that we have the most up to date mobile number for you. Updates to this information can be done when booking an appointment or in writing.In the future we may to wish to communicate with you via email. Please indicate if this would be a useful option for you and you would like to use this facility. I consent to receiving communication via email and understand my responsibility as set out below.It is essential that you understand that you are responsible for ensuring that we have the correct email address and who has access to this information. Updates only accepted in writing or via our online change of details form.Phone OptionalThis field is for validation purposes and should be left unchanged.