Under 16s New Patient Registration

Completing this form is the first step to registering with the practice.

We will send you a text message to confirm registration.

You will need to provide some identification on your first visit to the practice if you require  access to online services

• Patient Details
• Health Information
• Further Information

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Patient's Details

Title *

Miss

Master

Surname *

Date of Birth (DD/MM/YYYY) *

First names *

NHS Number

Previous surnames

Gender *

Male

Female

Town and country of birth *

Home address *

Postcode *

Name of current school

About You (Parent/Guardian)

Name of adult registering the child: *

Relationship to child: *

Parent/Guardian's Email Address: *

Parent/Guardian Telephone Number: *

Mobile number for text message reminders.

Parent/Guardian's Full Address inc postcode: *

How would you like us to contact you about your child? *

Letter

Email

Text

Phone

Who has legal parental responsibility? *

Mother

Father

Both

Other

Mother's full name: *

Mother's NHS number:

Is mother registered at this surgery? *

Yes

No

Does mother reside with the child? *

Yes

No

Father's full name: *

Father's NHS number:

Is father registered at this surgery? *

Yes

No

Does father reside with the child? *

Yes

No

Full Name: *

Relationship to child: *

Are you registered at this surgery? *

Yes

No

Is address the same as the child's? *

Yes

No

Address including Postcode: *

Carers Information

Is your child looking after someone?

Yes

No

eg. someone who is ill, frail, disabled, has mental health/emotional support issues or substance misuse

Relationship to child *

Does your child have a carer?

Yes

No

eg. family member, friend or neighbour

Carer's Name *

Carer's Phone Number *

Preferably a mobile number

Carer's Address *

Does your child need help with mobility/hearing/speaking? *

Yes

No

Please give details: *

eg. Wheelchair, hearing aid, braille, lip reading, sign language etc.

Is your child housebound?

Yes

No

Ethnic Origin

Please select the ethnic group which you consider your child belongs to *

White British White Irish Other White Black Caribbean Black African Other Black Black Caribbean and White Other Mixed Indian Pakistani Bangladeshi Other Asian I do not wish to state Other ethnic group (please state)

Is English your child's main spoken language? *

Yes

No

What is your child's main spoken language? *

Does your child need an interpreter?

Yes

No

What is your child's religion?

Church of England Catholic Buddhist Hindu Muslim Sikh Jewish Jehovah's Witness No Religion Other Religion:

Is your child currently:

Homeless

A refugee

A asylum seeker

Medical Records

Please help us trace your previous medical records by providing as much of the following information as possible.

Child's previous address in UK

Name of previous doctor while at that address

Address of previous doctor

If you are from abroad

Child's first UK address where registered with a GP

If previous resident in UK, date of leaving:

Date child first came to live in UK:

Please state all countries your child has lived in, or visited for longer than 6 months

Please include dates/years.