Under 16s New Patient Registration

Completing this form is the first step to registering with the practice. You will need to provide some identification on your first visit to the practice.

Registration Form (Child)

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    Background Details


    Your Child’s Details

    First Name
    Surname
    Date of Birth
    Address

    Parent or Guardian Details

    Address
    Do you consent to be contacted by SMS?
    Do you consent to be contacted by email?

    Other Details


    Previous GP

    Address

    Childs Other Details

    Ethnicity

    Religion

    Is your child an Overseas Visitor?
    Do you have any family members in the Armed Forces?

    Communication Needs


    Language

    Do you need an interpreter?

    Communication

    Does your child have any communication needs?

    Learning Disability

    Does your child have a Learning Disability?
    (If yes please request a Learning Disability Screening Tool form)

    Medical History


    Family History

    Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent.

    Medical problem
    Relative

    Allergies


    Current Medication

    Please check and include as much information about your child’s current medication below.

    Further Details


    Electronic Prescribing

    Please provide your full name

    Sharing Your Childs Health Record

    Do you consent to your GP Practice sharing your child's health record with other organisations who care for you?
    Do you consent to your GP Practice viewing your child's health record from other organisations that care for you?

    Your Childs Summary Care Record (SCR)

    Do you consent to your child having an Enhanced Summary Care Record with Additional Information?

    Please provide your full name
    Date
    This field is for validation purposes and should be left unchanged.