New Patient Registration Under 16

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All questions marked with a * are mandatory

Child's Details
Child's Title: *
 
 
Is the child younger than 42 days (6 weeks)?: *
 
Child's Gender at birth: *
Do they identify differently?:
UK Mobile only
Are you happy for us to contact you by email?:
Are you happy for us to contact you by text message? : *
 
Do you have or do you want to nominate a pharmacy for electronic prescribing?:
Nominate a pharmacy means we can send any prescriptions directly to the pharmacy without you needing to come to the surgery
include the full address and post code of your chosen pharmacy
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NHS

Your NHS Number

Help us to help you

You do not need to know your NHS number to use NHS services. However, providing this reduces the time it takes to process your registration. It helps us get you registered quicker.

  How to find your NHS Number

Help us to help you.

 

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Ethnicity & Religion
Does your child require an interpreter when you see the doctor/nurse?:
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Legal Guardian

The following questions are about the details of the Legal Guardian (i.e. Main Parent, Guardian or Carer) for  

Is the legal guardian registered at this practice?: *

Children cannot be registered unless their legal guardian is a patient at this practice, or unless they are planning to register at the same time.

You cannot continue with this application: *
Legal Guardian's Details
Legal Guardian's Title: *
Legal Guardian's Gender: *
 
 

You will be required to include copy of the Birth Certificate as proof later in this form.

please name all the people who live in the household with the child, and the relationship to the child.
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Previous Details
Are you registering your child with a GP for the first time in the UK?: *
Have you recently moved to the UK: *
Please include postcode
Are you returning from abroad?: *
If you are from abroad
Please use this date format: DD/MM/YYYY
Refugee: *
Asylum Seeker: *
Are you returning from abroad?: *
If you are returning from abroad

This assumes that you have previously been registered with the NHS in the UK

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Supplementary Questions - If you are not a resident in the UK, but visiting or moving to the UK
NHS

Anybody in England can register with a GP practice and receive free medical care from that practice.

However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice.

  • Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK.
  • Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.
  • More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available at reception. Alternatively for more information go to the NHS Website

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.

The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

Please select one of the following statements:: *
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European Economic Area (EEA) Country
Do you (as the legal guardian) live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?:
Do you (as the legal guardian) have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?:

Please Note

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

Please enter the details from your EHIC or PRC below.

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Carers

A carer is anyone, including children and adults who looks after a family member, partner, or friend who needs help because of their illness, frailty, disability, a mental health problem or an addiction and cannot cope without their support.

  • This does not mean your normal parenting duties for your child
Does your child have a carer?: *
UK number only
If a company of organisation, please indicate which above.
Do you give us permission to discuss your Child's medical record with their carer?: *: *
Does you child care for someone?: *
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Allergies
Does your child have any allergies?: *
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Lifestyle

Child's Height

What unit of measurement are you using?: *
Conversion from Feet & Inches to Centimetres

Child's Weight

What unit of measurement are you using?: *
Conversion from Stones & Pounds to Kilograms
Child's Smoking Status
Please choose from one of the following options: *
stop smoking

Steps to quit smoking

Stopping smoking lets you breathe more easily. People breathe more easily and cough less when they give up smoking because their lung capacity improves by up to 10% within 9 months.

  NHS Stop Smoking Services

  Take steps now to stop smoking

  10 self-help tips to stop smoking

Are they interested in advice on how to quit?: *
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Immunisation History

Please upload any records about vaccinations/immunisations/injections

  • You can upload a document, photo or scan of their redbook or vaccination book
  • It doesn't matter what language it is in, we can get it translated!
  • We will check if your child is due any additional/missing vaccinations and call you to book them an appointment with a nurse
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
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Medical History of your Child
Please include dates.
Please include dates.
Please include dates.
Please make sure you have a month’s supply from your previous practice and please arrange to make an appointment with your new doctor to review your ongoing medication.
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School
Is the child attending school?: *
Social Services
Does the child/family have any contact with a social worker?: *
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Document Uploads

Please upload a copy of the following documents

  • You can upload a document, photo or scan
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
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What happens to this information?

  • Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.
  • We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.
  • To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

You are signing this as   the of  

You are signing this as   the legal guardian of  

  • You have listed the reason for being the legal guardian as: 
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Privacy Consent

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