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New Patient Registration – Child (Under 16 years)

New Patient Registration – Child

Patient’s Details

Please complete text boxes as accurately as possible and select options where appropriate.
Please use day/month/year format. e.g. 04/10/2020
Can we contact you by text?
Can we contact you by email?
Please use day/month/year format. e.g. 04/10/94

Patient’s Previous Details

Please help us trace your previous medical records by providing the following information.
Please include postcode

Parent/Guardian Details

Are you next of kin?
Do you give us permission to discuss your full medical records with them?

Parent/Guardian Details

Are you their next of kin?
Do you give us permission to discuss your full medical records with them?


Do you have any allergies?


Please specify the ethnic group you consider you belong to *


Does your child take regular medication?
Does your child have any long-term illness, health problem or disability?

Please make an appointment for a new patient health check.

Electronic Prescribing

The Electronic Prescription Service (EPS) sends electronic prescriptions from GP practices to pharmacies. Eventually EPS will remove the need for most paper prescriptions.

Would you like to nominate a pharmacy for electronic prescribing? *


Does your child have any problems reading English? (school age children only)
Does your child have any problems speaking English?
If English is not your child’s main spoken language or yours, do you need an interpreter (someone to help with language) when you visit the doctor?

Immunisation History

Please include dates


Health Professionals

Does your child have contact with any of the following?
Has your child ever been under a Child Protection Plan?


My Data Matters

If you do NOT wish the NHS to share data from your health records for the purposes of research and planning, please opt out on the NHS website.

Summary Care Records (SCR)

These are an electronic record of important patient information, created from GP medical records. They can be seen and used bu authorised staff only; in other areas of the health and care system involved in the patients care.

To Opt Out, visit

NHS Organ Donor Registration

For more information on organ donation, please visit:

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 Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.