Under 16s New Patient Registration

Please upload birth certificate/proof of guardianship. Please also provide copies of immunisations (if aged under 5) *

Drop files here or

Max. file size: 50 MB.

Your Child’s Details

Parent or Guardian Details

Relationship to Child

Which other members of the family are registered with us? Optional

Child's country of birth

Name of school or nursery attended

Who has parental responsibility? (Both parents, or mother only, or father only)

Childs Other Details

Please give details of family members who are in the Armed Forces:

What is your childs main spoken language?

Tell us about any medical conditions your child has now, or had in the past

Any treatment at hospital?

If your child is currently under the care of a Hospital or Consultant outside our area, please tell us here:

Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent.

For Other please specify below Optional

Please record any allergies or sensitivities below Optional

Please check and include as much information about your child’s current medication below.

If they have a previous repeat medication list please give this to us and they may need a medication review appointment:

Electronic Prescribing

Please provide details of the pharmacy you would like to use so that we can send prescriptions electronically:

Parent or Guardian Signature

Please provide your full name

Sharing Your Childs Health Record

Your Childs Summary Care Record (SCR)

Parent or Guardian Signature

Please provide your full name

Name Optional

This field is for validation purposes and should be left unchanged.

Under 16s New Patient Registration

Registration Form (Child)

Background Details

Your Child’s Details

Parent or Guardian Details

Other Details

Previous GP

Childs Other Details

Communication Needs

Language

Communication

Learning Disability

Medical History

Family History

Allergies

Current Medication

Further Details

Electronic Prescribing

Sharing Your Childs Health Record

Your Childs Summary Care Record (SCR)