Child New Patient Registration (under 16)

If you are under 16 years old and would like to register with the practice please use this form.

To register a new patient you will need to live within our practice boundary.

Alternatively, you can download a paper copy of our Child New Patient Registration form below and hand it into the surgery:

New Patient Registration (Child under 16)

Child's Details

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Gender: *
Who else lives in this household?
Any responses we send will go to this email address
E.g. Mum, Dad etc.

Who has parental responsibility for this child

Child's Previous Details

Please include postcode

Child's Health History

Has your child had any serious illnesses or operations?
Does your child have a disability or chronic condition?

Child's Medication

Is your child on any regular medication? (If you have a list from your previous GP please give us a copy)
You may need to see the doctor for a first repeat prescription to be issued
Is your child allergic to any medication?

Child's Lifestyle

Does your child have contact with any of the following?
Has your child ever been under a Child Protection Plan?

Child's Immunisations

It is important that your child’s immunisations are kept up to date. A current photocopy of the immunisation history will help us to maintain their immunisation record; we can take a photocopy of this at reception. If this is not available then please list below:

Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY

Important

All the information given to the Practice as part of this form will be treated as Confidential. However to give your child the very best health care, we work closely with the Health Visiting and School Nursing Service. It is therefore normal practice to share details of all children registering with the Practice with our NHS colleagues in Health Visiting and School Nursing.

If you would prefer that we do not do this, tick here:

Child's Ethnicity and Language

Do you need an interpreter or sign language support?
In order to help provide the best possible care for patients with specific needs, our local Primary Care Trust has asked us to obtain details of your ethnicity. This information is entirely confidential. If you would prefer not to give it, please indicate below:

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.