Child New Patient Registration (Under 18)

As your child is a new patient to the practice, please submit this form.

Please bring the child’s red book when you attend for a New Patient Health Check.

To register a new patient you will need to live within our practice boundary.

All information on this form will be kept confidential. Please note, it is your responsibility to keep the organisation up to date with any changes to your address, telephone number or email address.

Child New Patient Registration (Under 18)

Patient Details

Please use date format: DD/MM/YYYY
Is your child home schooled?

Previous Details

Has your child been registered here previously?

If your child is from abroad

Please use the format: DD/MM/YYYY

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)

Next of Kin (Emergency Contact - If different from above)

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.
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)?

Parent or Guardian Declaration

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