Online Registration Form (patients aged 5 – 15 yrs) All information supplied is treated confidentially and forms a part of you medical record. Step 1 of 3 33% All patients registering at The Chislehurst Partnership will have full record view automatically enabled dating from the date of registration. Once you are registered for the Patient Access System you are able to; – make appointments – request prescriptions – view your GP medical record online If you would like to have secure online access to your historical records, we need to make sure that you understand what this involves and that you are happy for us to use the information provided below to set up and operate the service. If you wish to have historical access to your record, please complete and submit the Online Access Request FormName First Last Date of birth Day Month Year School currently attended Home NumberMobile Number OptionalFor reasons of confidentiality, patients aged 13 years and over must supply an individual mobile number.Email address Enter Email Confirm Email (must be different for each individual)Address Street Address Address Line 2 City Postcode 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)Please attach a copy of your latest list of medication to your application Optional Drop files here or Select files Max. file size: 50 MB. Are you are carer? Yes No Please give detailsDoes someone care for you? Yes No Please give detailsIs your first language English? Yes No First language Spoken Interpreter Required? Yes No What is your 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. OptionalIt 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. OptionalIt 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. Next of KinPlease complete as much detail as possible.Relationship to patient Optional Name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title Optional Given name Optional Surname Optional Address Street Address Optional Address Line 2 Optional City Optional Postcode Optional Home Telephone OptionalWork Telephone OptionalMobile Telephone OptionalEmail OptionalThis field is for validation purposes and should be left unchanged.