Child Registration Form This form is to be completed by patient representative on behalf of any child under 16. Patient's DetailsPlease enter patient detailsTitle Your Name First Name Surname Previous Surnames Optional (if applicable)Date of Birth Day Month Year NHS Number Optional (If known)EthnicityPlease Select…White BritishWhite IrishWhite OtherBlack BritishBlack CaribbeanBlack AfricanBlack OtherAsian IndianAsian PakistaniAsian ChineseAsian OtherWhite & Black BritishWhite & Black CaribbeanWhite & Black AfricanWhite & AsianOtherPlease specify your ethnicity SexPlease Select…FemaleMaleWas the patient born in the UK? Yes No Town and country of birth (If London please enter which borough)Date of entry to the UK Day Month Year Main Language Interpreter requried? (Please specify language required)Home Address Street Address Address Line 2 City Postcode (Please also provide flat number or room number where appropriate)Contact NumberEmail Address Enter Email Confirm Email Previous Medical RecordsPlease help us trace your previous medical records by providing the following information.Do you have a previous address in the UK? Yes No Your previous address in the UK Street Address Address Line 2 City Postcode Name of GP while at that address Address of previous GP Street Address Optional Address Line 2 Optional City Optional Postcode Optional Next of KinPlease give full details of patients next of kinDo you have any "Next of Kin" you would like us to contact in the case of an emergency? Yes No Name First Optional Last Optional Address Street Address Optional Address Line 2 Optional City Optional Postcode Optional Email Address Contact NumberRelationship to patient (e.g Mother, Father, Grandmother etc)Consent to discuss medical records Yes No Proof of identity and address Child Birth Certificate Child Red Book Patient representative proof of address Is the patient a carer Yes No Please provide detailsParent InformationWhen 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? Yes No Please provide us with the registered parents name Please provide us with the registered parents date of birth Day Month Year Please provide us with the registered parents current living address Street Address Address Line 2 City Postcode Medical InformationPlease enter any medical information for patient ie illnesses / operations/ accidents or disabilities.Please enter any medical conditions (If none, please enter ‘none’)Is the patient registered disabled? Yes No Please provide details Is the patient allergic to any medications? Yes No Please provide details Does the patient have any allergies? Yes No Please provide details Does the patient have any mental health conditions / issues? Yes No Please provide details Is the patient receiving any treatment or therapy? Yes No Please provide details File UploadPlease Attach Proof of Identity and Address Optional Drop files here or Select files Accepted file types: jpg, png, pdf, Max. file size: 1 GB, Max. files: 5. Complete RegistrationTo be completed by patient representativeSignature of patient representative
