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

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Shrewsbury School is a Registered Charity

Dear Parent / Guardian,

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

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: 01743 280860

Fax: 01743 280863

Senior Sister: Mrs Judith Lea ONC, RGN, RM, DiPP, ENP

Dental Officer: Mr R.J. Gatenby DS, DGDP, RCS

SHREWSBURY SCHOOL MEDICAL CENTRE 11 Ashton Road Shrewsbury Shropshire SY3 7AP Tel: (01743) 280860 E mail: medicalcentre@shrewsbury.org.uk Fax: 01743 280863

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Family doctor services registration

GMS1

Patient’s details Please complete in BLOCK CAPITALS and tick ■ as appropriate

■Mr ■Mrs ■Miss ■Ms Surname Date of birth First names

NHS Previous surname/s No.

■Male ■Female Town and countryof birth Home address

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 you first came date of leaving to live in UK

If you are returning from the Armed Forces

Address before enlisting

Service or Enlistment

Personnel number 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

Signature of PatientSignature on behalf of patient Date

Please see overleaf re: Organ donation

*Not all doctors are authorised to dispense medicines

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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)

Postcode:

To be completed by the doctor

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

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Shrewsbury School is a Registered Charity

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

Medical Officer: Dr Maurice Price MBBS London 1999 DRCOG. MRCGP

Senior Sister: Mrs Judith Lea ONC, RGN, RM, DiPP,ENP

Nursing Team: Mrs Christine Morgan RGN Mrs Kathryn Dovaston RGN, RSCN Mrs Lyn Morgan RGN

Mrs Megan Roberts RGN, RM Counsellor: Ms Wendy Brook: MBACP

Physiotherapist: Mr Alan Leigh: GDAMT (NZ) MSc MMACP

SHREWSBURY SCHOOL MEDICAL CENTRE 11 Ashton Road Shrewsbury Shropshire SY3 7AP Tel: (01743) 280860 E mail: medicalcentre@shrewsbury.org.uk judithlea@shrewsbury.org.uk Fax: 01743 280863

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Shrewsbury School is a Registered Charity

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).

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 www.immunisation.nhs.uk

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)

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Shrewsbury School is a Registered Charity

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.

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Shrewsbury School is a Registered Charity

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 01743 231001.

PRIVATE MEDICAL COVER

Does your child have private medical insurance? NO

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

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