New Patient Registration Form (Children: under 16s)

If you are registering a child under 5

I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance

If you need your doctor to dispense medicines and appliances*

*Not all doctors are authorised to dispense medicines

NHS Organ Donor registration

I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death. Please tick as appropriate

Confirm your consent to organ donation

NHS Blood Donor registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be pre p a red to donate blood

Check this if you have given blood in the last 3 years

For more information, please ask for the leaflet on joining the NHS Blood Donor

Looking After A Family Member

Is your child looking after someone?

Let us know if your child is looking after someone who is ill, frail, disabled or has mental health and/or emotional support needs, or substance misuse problems

Yes No

Is someone looking after your child?

Let us know if a family member, friend or neighbour looks after your child.

Yes No

Carer's Relationship with your child

Carer's Telephone No.

Is your child’s carer registered with us?

Yes No

Your Child’s Religion (Please State here)

Your Child’s Ethnic Origin

Does your child need an Interpreter?

If yes, which language?

Does your child need help with mobility/hearing/speaking?(Select all that apply)

If Other (Please state)

Is your child currently?

Is your child housebound?

Are there any serious diseases that affect your child’s parents, brothers or sisters?

State the family member if have
Diabetes

State the family member if have
Asthma

State the family member if have
Thyroid disorder

State the family member if have
Stroke

State the family member if have
COPD

State the family member if have
Heart Attack under age of 60

State the family member if have
Cancer (Specify type)

State the family member if have
High Blood pressure

Please state if someone in your family have any other
important illness

Please state any allergies and sensitivities that your child has to medicines, food & dressings

Please state any mental disabilities your child have

Are you able to administer your own medicines?

If no please give details, e.g. swallowing or opening containers

What chronic medical conditions has your child had?

What operations has your child had?

What injuries has your child had?

Please list any tablets, medicines or other treatments your child is currently taking / undertaking:

Immunisation for age: 2 Months

1st Diphtheria, Tetanus, Pertussis

Date of 1st Diphtheria, Tetanus, Pertussis

Immunisation taken from

GP Surgery Private Abroad

Immunisation taken from

GP Surgery Private Abroad

Immunisation taken from

GP Surgery Private Abroad

1st Pneumococcal Vaccine

Date of 1st Pneumococcal Vaccine

Immunisation taken from

GP Surgery Private Abroad

Date of 1st Rotavirus

Immunisation taken from

GP Surgery Private Abroad

Immunisation for age: 3 Months

2nd Diphtheria, Tetanus, Pertussis

Date of 2nd Diphtheria, Tetanus, Pertussis

Immunisation taken from

GP Surgery Private Abroad

Immunisation taken from

GP Surgery Private Abroad

Immunisation taken from

GP Surgery Private Abroad

1st Meningitis C

Date of 1st Meningitis C

Immunisation taken from

GP Surgery Private Abroad

Date of 2nd Rotavirus

Immunisation taken from

GP Surgery Private Abroad

Immunisation for age: 4 Months

3rd Diphtheria, Tetanus, Pertussis

Date of 3rd Diphtheria, Tetanus, Pertussis

Immunisation taken from

GP Surgery Private Abroad

Immunisation taken from

GP Surgery Private Abroad

Immunisation taken from

GP Surgery Private Abroad

2nd Pneumococcal Vaccine

Date of 2nd Pneumococcal Vaccine

Immunisation taken from

GP Surgery Private Abroad

2nd Meningitis C

Date of 2nd Meningitis C

Immunisation taken from

GP Surgery Private Abroad

Immunisation for age: 12 Months

Hib/Men C Booster

Date of Hib/Men C Booster

Immunisation taken from

GP Surgery Private Abroad

Immunisation for age: 13 Months

MMR (Measles, Mumps, Rubella)

Date of MMR (Measles, Mumps, Rubella)

Immunisation taken from

GP Surgery Private Abroad

3rd Pneumococcal Vaccine

Date of 3rd Pneumococcal Vaccine

Immunisation taken from

GP Surgery Private Abroad

Immunisation for age: 3½ to 5 years

MMR Booster (Measles, Mumps, Rubella)

Date of MMR Booster (Measles, Mumps, Rubella)

Immunisation taken from

GP Surgery Private Abroad

Pre- School Booster Diphtheria, Tetanus, Pertussis & Polio

Date of Pre- School Booster Diphtheria, Tetanus, Pertussis & Polio

Immunisation taken from

GP Surgery Private Abroad

Sharing Your Child'd Medical Record

Medical Record Sharing allows your child’s complete GP medical record to be made available to authorised healthcare professionals involved in their care. You will always be asked your permission before anybody looks at your child’s shared medical record.

If you don’t want to share your child’s GP record locally tick here

Summary Care Records containsdetails of your child’s key health information – medications, allergies and adverse reactions. They are accessible to authorised healthcare staff in A&E Departments throughout England. You will always be asked your permission before anybody looks at your child’s Summary Care Record.

If you don’t want your child to have a Summary Care Record tick here

The Care.data Programme Collates information about your child and the care they receive. It links information from all the different places where your child receives care, such as their GP, hospital and community services, to help them provide a full picture of your child’s medical needs and the care they are receiving. This data is made available to NHS Commissioners so that they can design integrated services and is shared with third parties for research purposes.

I wish to OPT OUT from my child’s Personal Confidential Data being shared outside their GP practice I wish to OPT OUT from my child’s Personal Confidential Data being shared with third parties

Second Parent's Name

Name of person with legal parental responsibility

Name of school attended

Parent / Guardian permission given

Permission given for someone other than a Parent/Guardian to accompany your child to an appointment?

New Patient Registration Form (Children: under 16s)

Please list other residents of your home who are registered with us

Please help us trace your previous medical records by providing the following information

If you are from abroad

If you are returning from the Armed Forces

NHS Organ Donor registration

NHS Blood Donor registration

Looking After A Family Member

Immunisation for age: 2 Months

Immunisation for age: 3 Months

Immunisation for age: 4 Months

Immunisation for age: 12 Months

Immunisation for age: 13 Months

Immunisation for age: 3½ to 5 years

Sharing Your Child'd Medical Record