Angel Lane Surgery

Tel: 01371 872 122

Fax: 01371 873679

BBC | Health News

2.0RSSBBC News | Health | UK EditionUpdated every minute of every day.'Debt deterring would-be doctors'The prospect of high student debt and increased pension contributions could discourage young people from entering medicine, a senior doctor warns.Sat, 19 May 2012 12:12:52 GMThttp://www.bbc.co.uk/news/health-18128637#sa-ns_mchannel=rss&ns_source=PublicRSS20-saDieting 'safe for pregnant women'Dieting in pregnancy is safe and does not carry risks for the baby, a review of research has suggested.Fri, 18 May 2012 01:36:38 GMThttp://www.bbc.co.uk/news/health-18101423#sa-ns_mchannel=rss&ns_source=PublicRSS20-saKids' cardiac service criticisedAn independent panel says cardiac services at Glasgow's Sick Children's Hospital "may be unsafe if critical staffing problems are not addressed".Fri, 18 May 2012 12:25:37 GMThttp://www.bbc.co.uk/news/uk-scotland-glasgow-west-18117882#sa-ns_mchannel=rss&ns_source=PublicRSS20-sa

Angel Lane Surgery
Angel Lane
Great Dunmow
Essex
CM6 1AQ

Telephone:
01371 872 122

PATIENT DETAILS

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PREVIOUS MEDICAL RECORDS

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ARE YOU RETURNING FROM THE ARMED FORCES?

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Address before enlisting

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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

NHS Organ Donor Registration

I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death.

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Kidneys	Heart	Liver	Corneas
Lungs	Pancreas	Any part of my body

Register Your Child

Would you like to register your child with the practice:

Please fill out this section if you are registering your child with the practice:

Date of Birth: First Name: Height:

Last Name: Parent/Guardian or Carere Telephone No:

Who does the child live with:? Was the pregnancy normal? Yes No

What school/Nusery does the child attend? Was the birth normal? Yes No

Has the child had any serious illness or operations?

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Is he/she regularly taking any tablets or medicines?

If yes please give details:

Are they allergic to any tablets/medicines?

If yes please give details:

What immunisation has he/she had and when?

Usual Age	Immunisation	Date Immunised
2 Months	DTaP/IPV/Hib and PCV
3 Months	DTaP/IPV/Hib, PCV and Men C
4 Months	DTaP/IPV/Hib, PCV and Men C
12 Months	Hib/Men C
13 Months	MMR and PCV
3 1/2 Years	DTaP/IVP or dTaP/IPV and MMR
Girls 12-13 Years	HPV
13-18 Years	Td/IPV

Sending this form does not guarantee or even imply that you will be accepted onto the practice register.

CONFIDENTIALITY - TERMS AND CONDITIONS:
The internet is not secure, and the transmission of this data is entirely at the patient's own risk. The practice accepts no responsibility for breaches in confidentiality resulting from patients' transmissions.

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