Child New Patient Registration (Under 18)

Patient Details

Please use date format: DD/MM/YYYY
What is the child’s sex as recorded on their NHS record?
Do you know the child’s NHS number?
Is your child home schooled?
Town and country of birth

Previous Details

Is the child registering with a UK GP for the first time?
Has your child been registered here previously?

If your child is from abroad

Please use the format: DD/MM/YYYY
Is the child returning from overseas?

Family Details

Parent / Guardian / Carer 1

All responses we send will go to this email address
Can we contact you by text? *
Can we contact you by email? *

Parent / Guardian / Carer 2

Who has parent responsibility? (Please select all that apply)
Does the child have a different emergency contact than listed above?

Emergency Contact

Next of Kin

Special Circumstances

Please select if any of the following apply to your child:

Other Information

Please specify what they are allergic to, what happens and when they had their first reaction.
Is your child:
Does your child suffer from any of the following:
Does your child have a family history of:
If possible, attach a copy of your child’s repeat prescription list.
Would you like to choose or change a pharmacy for the child’s prescriptions?
Does the child need a language interpreter?
Includes British Sign Language
Has the child ever been the subject of a child protection plan?
Has the child ever been a “Looked After” child (ie. in Foster Care or in a Children’s Home)?
Has a family member ever been registered with the Defence Medical Services? *

Parent or Guardian Declaration

I confirm that, to the best of my knowledge, the information I have provided is accurate and correct.