Child New Patient Registration

If you would like to register with the practice please use this form.

Please note, If you feel any question does not apply to you, please state ‘not known’ or ‘N/A’.

Child New Patient Registration

Child New Patient Registration

Patient's Details

Please use this date format: DD/MM/YYYY.
Sex *
Any responses we send will go to this email address.
Can we contact you by text? *
Can we contact you by email? *

Ethnicity

Please specify the ethnic group you consider you belong to: *

Next of Kin

Are they your next of kin? *
Do you give us permission to discuss your medical records with them? *

Allergies

Do you have any allergies? *

Previous Details

Please include postcode.

Lifestyle

Immunisation History

Please include dates.

Medical History

Have you ever needed treatment for any of the following?
Do you have any other medical problems we should know about? *
Do you have any problems with:
Please include dates. Please answer not known if you have no past medical history.
Please include dates. Please answer not known if you have no past medical history.
Please include dates. Please answer not known if you have no past medical history.
Please answer not known if you have no past medical history.
Sight: *
Hearing: *

Summary Care Record

Do you object to your summary care record being available when you access NHS care outside of your GP practice e.g. Out of Hours service or A&E? *

Nominate a Pharmacy

If you are on repeat prescriptions your prescription can be sent electronically to a pharmacy of your choice. Please let us know if you would like to nominate a pharmacy:

What happens to my information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.

To complete your registration please upload proof of identity, this should include Photographic ID and proof of address.
Maximum upload size: 67.11MB