Form: New Patient Registration (Under 12)

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Child's Details

It is of enormous benefit to the Doctors and Nurses to know something about your child's medical background when you visit the practice since we may not have received your child's notes from your previous practice for some time.
Please note all fields marked with a * are mandatory for your registration

if known
UK Mobile only
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
Main Parent/Guardian/Carer's Details
Please note: Children will not be registered unless their legal guardian is a patient at this practice, or unless they are planning to register at the same time
if known
please provide proof when you next visit the practice

Please submit birth certificate as proof when prompted.

please name all the people who live in the household with the child, and the relationship to the child.
Ethnicity & Religion
Social Services
If you are from abroad
Please use this date format: DD/MM/YYYY
If you are returning from abroad

Previously been registered with the NHS in the UK

Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
European Economic Area (EEA) Country

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.

Previous Details
Please include postcode, if you have never lived in the UK, type "never lived in UK before"
if you have never had a GP before, type "never had a GP in the UK before"

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

UK number only
If a company of organisation, please indicate which above.
Immunisation History

Please attach any records (such as your redbook/vaccination book) of vaccinations/ immunisations/ injections your child has had in the UK or from any other country (or bring into reception so we can take a photocopy)

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
Medical History of your Child
Please include dates.
Please include dates.
Please include dates.
include dosage, and frequency and what it is for

What happens to my 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.

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.


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