Child Patient Registration

When registering a new-born baby (less than 8 weeks old), please bring in the discharge summary provided by the hospital.

For registrations of children older than 8 weeks old, please bring the red book or any alternative document of immunisations.

Please read our welcome pack before completing your registration. This includes: the practice leaflet and welcome letter, the practice health records leaflet, the practice complaints procedure and the practice zero tolerance policy.

Child Patient Registration

Child Patient Registration

Child's Personal Details

Does your child have any special communication needs? *

If you have stated that your child has any special communication needs on this form, we will do our best to accommodate their needs. Should their needs change, please inform us.

Title: *
Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
Please state which number you would prefer us to use first to contact you about your child: *
Can we contact you by text? *
Can we contact you by email? *

Who Looks After Your Child:

Who has parental responsibility?

Please note that at least one person with parental responsibility must be registered at the practice.

Are they registered at the practice? *
Are they registered at the practice? *
Are there any court orders or restrictions on access to this child’s care or medical records? *
Does your child have a social worker? *

About Your Child

How would you best describe your child's gender: *
Is your child's gender identity the same as the gender they were given at birth? *
What is your child's ethnic origin? (Please tick the box that you feel best applies to you) *
Please specify your child's ethnic origin: *
Please specify your child's ethnic origin: *
Please specify your child's ethnic origin: *
Please specify your child's ethnic origin: *

Language

If English is not your child’s first language, do you require an interpreter to be arranged for your child’s appointments?

Allergies

Do you have any allergies? *

Previous Details

Please include postcode.

If you are from abroad

Registering with the NHS for the first time in the UK
Please use this date format: DD/MM/YYYY.
Please use this date format: DD/MM/YYYY.

Carers

Is your child a carer for a relative or neighbour? *
Would you like your child to be added the practice's carers register: *

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 Medical History

Does your child suffer with sight loss?
Does your child suffer with hearing loss?
Does your child need help with mobility?
Does your child have a learning disability?
Does you child suffer with a disability not stated above?
Is your child housebound?

Children 10-15 Years Old

For 10-15 year olds only. For children younger than 10-15, go straight to the medication section below.

Child Medication History

If your child has a repeat medication slip from your previous GP, please attach of copy of this to this form by using the file upload feature.

Electronic Prescribing Service: The practice can send your child’s prescription to your preferred pharmacy electronically. Please inform us if you have nominated a pharmacy in another area and you now wish to change to a local pharmacy.

Online Access

We are able to offer online access for children. This is revoked automatically at the age of 12, and we ask for a new application to be made with your child’s consent. If you have any questions about this, then please speak with a member of our reception and administration team or send the practice an email.

If you wish to have for your child to have online access via Patient Access in order to book appointments, request repeat prescriptions or to access their medical record, please complete the following:

I wish to have access to the following online services for my child:
Please complete the following to confirm that that you have understood and agree with each statement. (Please tick to indicate that you agree): *

Data Protection and Sharing

In accordance with the Data Protection Act, the practice needs consent from any patient for us to leave a message, send a text or information regarding their medical treatment. By providing information on this form you are consenting to be contacted about your child's medical needs by the practice.

Regarding results, appointments or other medical issues relating to my child:

I give permission to be contacted via text message: *
I give permission for a voicemail to be left: *
I give permission to be contacted via email: *

Data Research

To opt out of ‘National Data’, please visit www.nhs.uk/your-nhs-data-matters/manage-your-choice/

Summary Care Record

Summary Care Records (SCR) are an electronic record of important patient information, created from GP medical records. They can be seen and used by authorised staff in other areas of the health and care system only when involved in your direct care.

Giving your consent for authorised healthcare staff to have access to this important information means that they are able to make informed decisions particularly in an emergency or out of hours when your GP surgery is closed.

More information is available at: NHS: Summary Care Record Information

I wish to register my child for the Summary Care Record: *
Please tick the appropriate box:
Please confirm the following: *

Declaration

By signing this form, I confirm that I have read the following and agree to abide by the details included in each: *

We thank you for completing this form. If you require any more information on the practice, please return to our homepage after submitting this form. If your details change, or you would like to change your choices regarding how we contact you or share your data, please inform us.

Please upload any relevant evidence in support of your registration.
Maximum upload size: 67.11MB