New Patient Registration Form (Under 16)

Required Information

Name
Date of Birth
Gender
Email Address
Current Address
Previous Address
If from abroad, the date of entry to the UK
Has the child lived outside the UK?

About You (Parent or Guardian)

Name of adult registering the child
Are you registered or registering at this practice?
Parent/Guardian's Full Address
Do you consent to be contacted by SMS?
Email
Do you consent to be contacted by email?

Next of Kin / Name of person(s) with legal parental responsibility

Name
Date of Birth
Gender

Is your child home educated?
Please state name, relationship to child & if they are registered with us

Private Caring Arrangements

Is your child being looked after by a friend, neighbour in their home?
Is someone looking after your child at home?
Carer’s Name
Carer’s Address
Please tick if your child is currently
Is your child currently housebound?
Is the child a ‘child looked after’ under the care of the local authority?
Is your child or family currently involved with Children’s Social services or have they ever been known to Children’s Social services or the safeguarding team?

Your Child’s Background Information. Due to government policy, we are obliged to ask you the following:

Do you need an interpreter?

Communication Needs

Does your child have any communication needs?

Looking after a family member/carer

Please let us know if your child is looking after someone who is ill, frail, disabled, has mental health/emotional support needs, or substance misuse.
Is your child looking after someone at home?

Your Child’s Medical Background

Please state the condition, year diagnosed and if it is ongoing
Is your child registered with a dentist?
To find a dentist visit NHS Choices www.nhs.uk
Please state the name of medication, dosage & frequency

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

Immunisation History

Your Child’s Pharmacy Services

Sharing your child’s medical record

Parent/Guardian permission given

Permission given for someone other than a Parent/Guardian to accompany your child to an appointment? E.g. Grandparent, Nanny, childminder

Thank you for completing this form

Please see our practice leaflet/website for further information about our team/services.

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