New Patient Registration Child Please complete the online form to register as a new patient. New Patient Registration Child Step 1 of 2 50% Please Note: A supporting signed letter from the patient will be required either posted or emailed to the practice, to complete the registration.Background DetailsContact DetailsNHS Number Optional Title DrMissMrMrsMsProf.Rev. Prefix Name Gender Please SelectFemaleMaleDate of Birth Day Month Year Address* Street Address Address Line 2 City Post code Contact Number Parent / Guardian DetailsParent / Guardian Name Relationship to child Address* Street Address Address Line 2 City Post Code Contact Number Do you content to be contacted via SMS? Please SelectYesNoEmail Enter Email Confirm Email Do you consent to be contacted Via email? Please SelectYesNoNext of KinDo you have a next of kin? Please selectYesNo(emergency contact person)Name Phone Relationship to you Previous GPGP Name Address* Street Address Address Line 2 City Post Code Other Child DetailsCountry of Birth Ethnicity Please SelectWhite (UK)White (Irish)White (Other)Black CaribbeanBlack AfricanBlack OtherBangladeshiIndianPakistaniChineseOtherReligon Optional Please SelectC of ECatholicOther ChristianBuddhistHinduMuslimSikhJewishJehovah's WitnessNo ReligionOtherEmployment Status Optional Please SelectEmployedSelf-employedStudentUnemployedHouse HusbandHouse WifeCarerRetiredAre you an overseas visitor Please SelectYesNoIf you hold a European Health Insurance Card Please contact us with details of this.Communication NeedsWhat is your main spoken language? Do you need an interpretor? Please SelectYesNoDo you have any communication needs? If yes: What?Do you have a learning disability? Please selectYesNoIf Yes please request a Learning Disability Screening Tool formIf you are being supported by Social Services or Children’s Services, please tell us here: Optional Medical HistoryHave you suffered from any of the following conditions? Please SelectNoneAsthmaEpilepsyDiabetesDepressionCancerAny other conditions, operations or hospital admission details: Optional If you are currently under the care of a Hospital or Consultant outside our area, please tell us here: Optional Family HistoryPlease record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent.Relative Optional i.e Parent, Sibling, Grandparent, Aunt/Uncle/Cousin etcMedical Problem Optional AllergiesPlease record any allergies or sensitivities MedicationPlease check and include as much information about your current medication below.Please give us your previous repeat medication list if possible, a medication review appointment may be needed: Optional Electronic PrescribingIf you would like your prescriptions to be sent electronically, please provide details of the pharmacy you would like to use: Optional I confirm that the information I have provided is true to the best of my knowledge.Parent / Guardian Name Date Day Month Year Your Health Record I wish to give EXPRESS CONSENT for medication, allergies and adverse reactions only to be included in my Summary Care Record I wish to give EXPRESS CONSENT for medication, allergies, adverse reaction and additional information to be included in the my Summary Care Record I DO NOT CONSENT to have my Summary Care Record and do not wish to have one Yes (recommended option) No Your Summary Care Record (SCR) Yes (recommended option) No Please upload a photo of your child's ID / Address / Birth certificate Optional Drop files here or Select files Max. file size: 50 MB.