Child New Patient Registration

If you would like to register a child with the practice please use this form.

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

Child New Patient Registration Form

Child's Personal Details:

Title:
Gender:
Use date format DD/MM/YYYY
Note, we use the mobile number for text messages. Test messages will automatically cease when the child is 11 years old.
Any responses will be sent to this email address.

Parent/Carer Details:

Legal/Parental Responsibility?
Next of Kin?
Legal/Parental Responsibility?
Next of Kin?

Child's Needs:

Does the child have any special communication/mobility needs?
If yes:
Is the child currently:
Is the child in care?
Is the child a "looked after child"?
In what capacity?
Is the child home educated?
Has the child or family either currently or in the past been known to Children's Services?

Required Information:

Is your child looking after someone at home? *
Do you think the child would like additional support as a young carer? *
Is the child known to services such as Young Carers? *
Is the child being privately fostered? (see definition below) *
Are Children's services aware? *
Private fostering is an arrangement whereby a child under the age of 16 (or 18 if the child has a disability) (S.66 Children Act 1989) is placed for 28 days or more in the care of someone who is not the child’s parent(s) or a ‘connected person’. Private foster carers can be from the extended family, e.g. a cousin or a great aunt, but cannot be a relative as defined under the Children Act 1989, section 105:‘A relative under the Children Act 1989 is defined as a ‘grandparent, brother, sister, uncle or aunt (whether full blood or half blood or by marriage or civil partnership) or step-parent’.

Please help us trace the child's previous medical records by providing the following information:

If you are from abroad:

Use date format DD/MM/YYYY
Use date format DD/MM/YYYY

If you are registering a child under 5:

If you need your doctor to dispense medicines and appliances:

For dispensing practices only:

Supplementary Questions

I am not ordinarily a resident in the UK

Ordinarily Resident

Anybody in England can register with a GP practice and receive free medical care from that practice.

However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK.

Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.

More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice. Alternatively for more information go to www.nhs.uk/visitingengland.

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.

The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

Please select one of the following statements:

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate
action may be taken against me.

A parent/guardian should complete the form on behalf of a child under 16.

European Economic Area (EEA) Country

For a list of EEA countries visit: www.gov.uk/eu-eea
Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?
Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?

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.

EHIC/PRC

Please enter the details from your EHIC or PRC below.

S1 Form

Do you have an S1 Form?
Please give your S1 form to the practice staff.

How will your EHIC/PRC/S1 data be used?

By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process.

Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

Child's Personal Medical History:

If under 5 years, type of birth:
Has your child ever suffered from any important medical illness, operation or admission to hospital?

Family Medical History:

Have any close relatives (parents and siblings only) ever suffered from any of the following:
Heart Disease:
At the time of diagnosis they were:
Stroke:
At the time of diagnosis they were:
Diabetes:
At the time of diagnosis they were:
High blood pressure:
At the time of diagnosis they were:
Asthma:
At the time of diagnosis they were:
Glaucoma:
At the time of diagnosis they were:
Cancer:
At the time of diagnosis they were:
Mental Health Problems:
At the time of diagnosis they were:
Renal/Kidney:
At the time of diagnosis they were:
Learning Disabilities:
At the time of diagnosis they were:

Child's Immunisations:

Please provide details of your child's immunisation with dates if possible (under 5's). If possible please give your Red Book to reception to photocopy.
Use date format DD/MM/YYYY
Use date format DD/MM/YYYY
Use date format DD/MM/YYYY
Use date format DD/MM/YYYY
Use date format DD/MM/YYYY
Use date format DD/MM/YYYY
Use date format DD/MM/YYYY
Use date format DD/MM/YYYY
Use date format DD/MM/YYYY
Use date format DD/MM/YYYY
Use date format DD/MM/YYYY
Use date format DD/MM/YYYY

Child's Medications:

Child's Allergies:

Child's Ethnicity:

Child's Religion:

Please advise if you feel your child's religion will affect any treatment received:

Child's Language:

Does the child need an interpreter?

Data Sharing Consent Choices:

To maintain continuity of clinical care, we upload certain medical information so that it is available to other healthcare organisations (eg Emergency Departments).

Where you have provided information on how to contact you, can you confirm you are happy for the practice to contact you by the following:

By email:
This will be to send you letters, the practice newsletters and the like
By text:
This will be to send you reminders of appointments via text

Signatures:

*
*