And finally please do not forget to SIGN the form at the bottom front.

Transcription

1 Shrewsbury School Sanatorium 11 Ashton Road, Shrewsbury, SY3 7AP Medical Officer: Dr Maurice Price MBBS London 1999 DRCOG MRCGP Senior Sister: Judith Lea, ONC, RGN, RM, DiPP, ENP Telephone: Fax: SHREWSBURY SCHOOL MEDICAL CENTRE 11 Ashton Road Shrewsbury Shropshire SY3 7AP Tel: (01743) E mail: [email protected] Fax: Senior Sister: Mrs Judith Lea ONC, RGN, RM, DiPP, ENP Dental Dear Officer: Parent / Guardian, Mr R.J. Gatenby DS, DGDP, RCS In order for us to register your child with the School s Medical Officer, we need you to complete both forms enclosed. 1. The purple Family doctor services registration form, GMS1. 2. Shrewsbury School New Pupil Medical Form. These forms are an important part of your child s registration process. Please complete and return to the School s Medical Centre BEFORE the start of term. Advice for completing purple Family doctor services registration form, GMS1 form:- 1. Home address is your child s boarding address at Shrewsbury School. 2. Your previous address in the UK is the last address your child was living at when registered with a GP (e.g. the last boarding or prep school address OR home if you haven t been a boarder before). 3. Name and address of your child s last Doctor this must be the Doctor your child was registered with at the address noted above. 4. NHS number - you may obtain this from your child s last registered Doctor s practice OR from their Medical Card. If your child has never lived in the UK before, it will be issued on registration with Shrewsbury School s Medical Officer. 5. If coming from abroad, we will need to know the previous address when you last lived in the UK and the dates your child left and returned. 6. If your child has never lived or been registered with a Doctor in the UK before, we will need:- THE EXACT DATE OF YOUR CHILD S ARRIVAL IN THE UK A PHOTOCOPY OF YOUR CHILD S ID IS HELPFUL (E.G. PASSPORT). And finally please do not forget to SIGN the form at the bottom front. Thank you

2 Family doctor services registration GMS1 Patient s details Mr Mrs Miss Ms Date of birth Surname First names Please complete in BLOCK CAPITALS and tick as appropriate NHS No. Male Female Home address Previous surname/s Town and country of birth Postcode Telephone number Please help us trace your previous medical records by providing the following information Your previous address in UK Name of previous doctor while at that address Address of previous doctor If you are from abroad Your first UK address where registered with a GP If previously resident in UK, date of leaving Date you first came to live in UK If you are returning from the Armed Forces Address before enlisting Service or Personnel number Enlistment date If you are registering a child under 5 I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance If you need your doctor to dispense medicines and appliances* I live more than 1 mile in a straight line from the nearest chemist I would have serious difficulty in getting them from a chemist *Not all doctors are authorised to dispense medicines Signature of Patient Signature on behalf of patient Date Version 01/02 Please see overleaf re: Organ donation

3 Family doctor services registration GMS1 NHSOrgan Donor registration I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death. Please tick as appropriate Kidneys Heart Liver Corneas Lungs Pancreas Any part of my body Signature confirming consent to organ donation Date For more information, please ask for the leaflet on joining the NHS Organ Donor Register NHSBlood Donor registration I would like to join the NHS Blood Donor Register as someone who may be contacted and would be pre p a red to donate blood. Tick here if you have given blood in the last 3 years Signature confirming consent to inclusion on the NHS Blood Donor Register Date For more information, please ask for the leaflet on joining the NHS Blood Donor Register My preferred address for donation is: (only if different from above, e.g. your place of work) To be completed by the doctor Postcode: Doctors Name HA Code I have accepted this patient for general medical services For the provision of contraceptive services I have accepted this patient for general medical services on behalf of the doctor named below who is a member of this practice Doctors Name, if different from above HA Code I am on the HA CHSlist and will provide Child Health Surveillance to this patient or I have accepted this patient on behalf of the doctor named below, who is a member of this practice and is on the HA CHS list and will provide Child Health Surveillance to this patient. Doctors Name, if different from above HA Code I will dispense medicines/appliances to this patient subject to Health Authority s Approval I am claiming rural practice payment for this patient. Distance in miles between my patient s home address and my main surgery is I declare to the best of my belief this information is correct and I claim the appropriate payment as set out in the Statement of Fees and Allowances. An audit trail is available at the practice for inspection by the HA s authorised officers and auditors appointed by the Audit Commission. Practice Stamp Authorised Signature Name Date HA use only Patient registered for GMS CHS Dispensing Rural Practice

4 Medical Officer: Senior Sister: Nursing Team: Counsellor: Physiotherapist: Dr Maurice Price MBBS London 1999 DRCOG. MRCGP Mrs Judith Lea ONC, RGN, RM, DiPP,ENP Mrs Christine Morgan RGN Mrs Kathryn Dovaston RGN, RSCN Mrs Lyn Morgan RGN Mrs Megan Roberts RGN, RM Ms Wendy Brook: MBACP Mr Alan Leigh: GDAMT (NZ) MSc MMACP SHREWSBURY SCHOOL MEDICAL CENTRE 11 Ashton Road Shrewsbury Shropshire SY3 7AP Tel: (01743) E mail: [email protected] [email protected] Fax: CONFIDENTIAL NEW PUPIL MEDICAL FORM Dear Parent/Guardian, Please complete ALL sections of this medical form providing us with as much information as possible so that we can register your child with the School s Medical Officer, enabling us to provide the most effective medical care whilst at Shrewsbury School. Please visit the school website and follow the link for full information about the Medical Centre. PLEASE RETURN THIS FORM TO THE MEDICAL CENTRE BEFORE THE START OF TERM. Pupil s Full Name Date of Birth Home Address(es), Where Next of Kin Reside Contact Telephone Numbers First Language School Boarding House

5 ETHNIC ORIGIN Please indicate pupil s ethnic origin. This is not compulsory, but it may help with healthcare, as some health problems are more common in specific communities and knowing your origins may help with the early identification of some of these conditions. Please tick ONE box that best describes the pupil. (This part of the form follows the recommendations of the Commission for Racial Equality and complies with the Race Relations Act). WHITE: British Irish Other (please specify) MIXED: White & Black Caribbean White & Black African White & Asian Other (please specify) ASIAN OR ASIAN BRITISH: Indian Pakistani Bangladeshi Other (please specify) BLACK OR BLACK BRITISH: Caribbean African Other (please specify) CHINESE OR OTHER ETHNIC GROUP: Chinese Other (please specify) CHILDHOOD IMMUNISATIONS Please ensure your son/daughter is up to date with their routine childhood immunisations. It is important that they have already received 2 x MMR vaccinations as a young child to prevent the spread of measles which has reappeared in the Shropshire area. Please let us know in the box below if your son/daughter has NOT received 2 x MMR vaccinations as a younger child and state your reasons why. As a continued part of your son s or daughter s Childhood Immunisation Programme they will require a school leaver s Diphtheria, Tetanus and Polio vaccination AND a Meningitis C vaccination. Please confirm below whether or not you give your consent for your child to receive the above vaccinations. NO YES Do you give consent for your child to receive an annual influenza (flu) injection during their stay at Shrewsbury School during October/November? NO YES For more information visit

6 Has your child ever suffered from the following conditions? CONDITION NO YES (More details please) Asthma Hayfever Eczema Diabetes Kidney Disorders Bones/Joint Disorders Heart Condition Epilepsy Chicken Pox Measles Mumps Glandular Fever Ear Infections/Deafness Bed Wetting Depression/Anxiety Disorders ANY OTHER Please note below if your child has any ALLERGIES including food/medicines/plasters? Please note below if your child takes any medicine oral, liquids, tablets, inhalers, creams, sprays? If your child is currently taking medication please inform House Matron at the start of term. Please note below if there is any other feature of your child s physiological health and well being which you think the School doctor should be made aware of or which you would like to discuss.

7 DENTAL It is important that parents register their child with a dentist at home and we expect routine treatments to take place there. If a pupil is not registered at home, any necessary treatment may have to be delayed or provided on a private basis. During term time all emergency treatments and the fitting of gum shields will be undertaken by Mr R J Gatenby, New Park House Dental Centre, Brassey Road, Shrewsbury SY3 7FA; telephone PRIVATE MEDICAL COVER NO Does your child have private medical insurance? YES If YES, please state: Company Name Policy Number Expiry Date CONSENT I empower the Headmaster, Second Master or Housemaster to give consent for any emergency treatment, including surgical operations, if it is impossible to contact me personally. I authorise the School to administer first aid and appropriate medication, when required SIGNATURE OF PARENT/GUARDIAN DATE Thank you for taking the time to complete this form.