Child Registration Form

This form is to be completed by patient representative on behalf of any child under 16.

Patient's Details

Please enter patient details
Your Name
(if applicable)
Date of Birth
(If known)
Was the patient born in the UK?
(If London please enter which borough)
(Please specify language required)
Home Address
(Please also provide flat number or room number where appropriate)
Email Address

Previous Medical Records

Please help us trace your previous medical records by providing the following information.
Do you have a previous address in the UK?
Address of previous GP

Next of Kin

Please give full details of patients next of kin
Do you have any "Next of Kin" you would like us to contact in the case of an emergency?

Parent Information

When registering a child with a GP practice, the child must have at least one parent (or legal guardian) registered at the same GP practice. Please note, we will be unable to register the child if this condition isn’t met.
Are at least one of the Child's parents registered at Andover Medical Centre?

Medical Information

Please enter any medical information for patient ie illnesses / operations/ accidents or disabilities.
(If none, please enter ‘none’)
Is the patient registered disabled?
Is the patient allergic to any medications?
Does the patient have any allergies?
Does the patient have any mental health conditions / issues?
Is the patient receiving any treatment or therapy?

File Upload

Drop files here or
Accepted file types: jpg, png, pdf, Max. file size: 1 GB, Max. files: 5.

    Complete Registration

    To be completed by patient representative