New Patient Registration (Under 16)

If you would like to register a child (under 16) with the practice please use this form. Before Registering a child please make sure that a parent or guardian has also filled in a registration form or is already registered at the practice.

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


Registration Form (Child)

1. Background Details


Your Child’s Details

Title *
Gender *
Current Address
Current Address
Previous Home Address
Previous Home Address
We use the mobile number for text messages. Text messages will automatically cease when the child is 11 years old.

By filling in the above you consent to be contacted by SMS on this number

By filling in the above you consent to be contacted by email at this number
It is your responsibility to keep us updated with any changes to your telephone number, email & postal address. We may contact you with appointment details, test results, health campaigns or Patient Participation Group details.

 

Parent, Guardian or Carer Details 1

Please fill in the below detail for a parents, guardian or carer. At least one needs to be filled in.
Are they your next of kin? *
Do they have legal/parental responsibility? *

Parent, Guardian or Carer Details 2

Are they your next of kin?
Do they have legal/parental responsibility?

If neither of the above, person with legal responsibility


Other Details

Previous GP

Previous GP Surgery Address
Previous GP Surgery Address

Ethnicity *
Please advise if you feel your child religion will affect any treatment received
As a practice, we fully support the Armed Forces Covenant. We can only do this if we know our patients connections to the Armed Forces. Please click the box below

Is the child currently
Is the child a child in care?
Is the child a “Looked after child”?
If ‘Yes’, to either of the above two questions, 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?
Is the child being privately fostered (see definition below)?
Please tell is if the child is looking after someone who is ill, frail, disabled, has mental health/emotional support needs or substance misuse problems
Is Children’s services aware?

Carer

Is the child looking after someone at home?
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-parents’.
Do you think the child would like additional support as a young carer?
Is the child known to services such as Young Carers?


Communication Needs

Language

Do they need an interpreter?

Communication

Does the child have any communication needs? *
Please specify below

Learning disability

Does the child have a diagnosed Learning Disability? *

Mobility

Does the child have any mobility issues? *