New Patient Registration for age 12 and under

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. 04/10/59
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?

Allergies

Do you have any allergies?

Ethnicity

Please specify the ethnic group you consider you belong to *

Health

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? *

Language

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. NB. We may not be able to proceed with your child’s registration if we do not receive a list of your child’s immunisations (from 0-19 years of age). This can be easily obtained from your previous surgery. You are welcome to send this as an attachment at the end of this form.

School/Nursery

Health Professionals

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

Brother/Sisters/Siblings

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 www.digital.nhs.uk/scr

NHS Organ Donor Registration

For more information on organ donation, please visit: www.organdonation.nhs.uk

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.

Type your name here to represent your signature
Type your name here to represent your signature

Confirm ID and Upload Documents

Anybody in England, whether a resident or overseas visitor, may access primary care services at a GP Practice without charge. No documents are required to register with a GP; however, to facilitate the registration process we would request that two forms of identification are produced, ideally if possible, one should be photographic, and one must contain your address. You may be asked to sign a Practice Form to give your permission for us to retain these documents with your electronic patient record. 

These documents may be used to confirm your details with our local Health Authority. This also helps to ensure the correct matching of your details to any existing NHS record, enabling previous medical records to transfer smoothly between practices. We appreciate your assistance in this matter.

Types of acceptable photographic evidence:

  • Passport
  • Drivers Licence
  • Official ID card from Public Services body; or
  • Student matriculation card (current year)

Other documents for proof of residency that are acceptable are:

  • Recent utility bill (within last 3 months)
  • Council Tax document
  • Television Licence
  • Payslips (last two months)
  • Rent book/agreement (Public Body or Private Landlord)
  • Bank Statement (Name and address section only required)
  • Solicitors Letter (Clearly showing your name and address)

If you are unable to provide photographic evidence then we would request you provide one of the above and one of the following:

  • Birth Certificate
  • Marriage Certificate
  • Divorce Annulment Papers

If you are unable to provide any documentation, then we may still register you. However we may need to contact our Registration Department first, to verify your information with them, and ensure your medical records are not delayed in being transferred to the Practice. This will normally involve a phone call between you, our Registration Department and ourselves. Alternatively we may also email/write to them directly in which case we will require your consent for us to do so.

If you have any questions regarding NHS entitlement, or our Registration Policy please contact the Practice.

How will you provide documentation? *

Maximum file size: 2MB

We accept jpg, gif, png, pdf and Word files up to 2 MB.

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.