Child New Patient Registration

Your Child/ Young Person’s Details

You can find this on a prescription or by contacting your GP.
What is the sex as recorded on the child’s/young person’s NHS record? *
Is the gender identity the same as the sex they were assigned at birth? *
We are asking for this information to match GP record.

Previous Details

Mark N/A if this does not apply.
Has the child/young person ever lived somewhere else in the UK?

Family/ Guardians

Has Legal Responsibility? *
Next of Kin? *
Has Legal Responsibility?
Next of Kin?

Please provide a copy of Delegation of Consent Form if you are a carer.

Please state if they are also registered with the practice.

Patients under 12 months

Where were they born?
Full address and postcode

Patients under 18 years

Do they attend any of the following:
Are any of these involved in their care?
Have all routine vaccinations been had?
Were the routine vaccinations given in the UK?

Ethnicity

What is the child’s/young person’s ethnicity?

Additional Information

Please use format DD/MM/YYYY
Does the child/young person need an interpreter for appointments?
Please select if any of the following apply to your child/ young person:
Does your child/ young person need help with mobility/ communication?
Do they have a carer?
What type of carer are they?
Are they a young carer under 18?

Child’s Medical Background

In KG or Stone & Pounds
In CM or Feet & Inches
Has the child/young person ever had any of these conditions?
Include condition names, year diagnosed and whether this is an ongoing problem.
Is your child registered with a dentist?
Is your child/ young person known to Social Services?
Is your child or family currently involved with Children’s Services?
Is your child/ young person a Looked After Child in the care of the Local Authority?
Is this?
Would you like an appointment to discuss this with your doctor?
Is your child being looked after by a friend, family member or neighbour in their home (Private Fostering)?
Is your child looking after someone at home?
Please let us know if your child is looking after someone who is ill, frail, disabled, has mental health/ emotional support needs or substance misuse problems.
Do you think they would like additional support as a young carer?
Would you like an appointment with your doctor to discuss this?