Child Registration - Dearden Avenue Medical Practice

Boundary Area

Catchment Area

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

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

All patients are asked to provide proof of identification if possible (children registering with their families don’t have to provide this).

Non-British citizens will also need to provide proof of entitlement to free NHS treatment; this can be a health insurance card or a current residence permit/immigration status.

Child Registration Form

Please upload birth certificate/proof of guardianship. Please also provide copies of immunisations (if aged under 5) *

Drop files here or

Max. file size: 50 MB.

Background Details

Your Child’s Details

Title

NHS Number

First Name

First

Surname

Last

Gender

Date of Birth

Day

Month

Year

Address

Street Address Address Line 2 City Postcode

Contact Number

Parent or Guardian Details

Your Name

Relationship to Child

Address

Street Address Address Line 2 City Postcode

Home Telephone Optional

Work Telephone Optional

Mobile Telephone

Do you consent to be contacted by SMS?

Yes

Do you consent to be contacted by email?

Yes

Family Registered with Us Optional

Other Details

Previous GP

Name of Previous GP

Address

Street Address Address Line 2 City Postcode Country

Childs Other Details

Country of Birth

Ethnicity

White (UK)

White (Irish)

White (Other)

Black Caribbean

Black African

Black Other

Bangladeshi

Indian

Pakistani

Chinese

Other

Religion

C of E Optional

Catholic Optional

Other Christian Optional

Buddhist Optional

Hindu Optional

Muslim Optional

Sikh Optional

Jewish Optional

Jehovah’s Witness Optional

No Religion Optional

Other Optional

Is your child an Overseas Visitor?

Yes

European Health Insurance Card Held (please bring details with you)

Do you have any family members in the Armed Forces?

Yes

Please give details of family members who are in the Armed Forces:

Communication Needs

Language

What is your childs main spoken language?

Do you need an interpreter?

Yes

Communication

Does your child have any communication needs?

Yes

Please specify

Hearing aid

Lip reading

Large print

Braille

British Sign Language

Makaton Sign Language

Guide dog

Learning Disability

Does your child have a Learning Disability?

Yes

(If yes please request a Learning Disability Screening Tool form)

Medical History

Has your child suffered from any of the following conditions?

Asthma Optional

COPD Optional

Epilepsy Optional

Heart Disease Optional

Heart Failure Optional

High Blood Pressure Optional

Diabetes Optional

Kidney Disease Optional

Stroke Optional

Depression Optional

Underactive Thyroid Optional

Cancer Optional

For Cancer, please specify which type

Any other conditions, operations or hospital admission details: Optional

If your child is currently under the care of a Hospital or Consultant outside our area, please tell us here: Optional

Family History

Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent.

Medical problem

Asthma Optional

COPD Optional

Epilepsy Optional

Heart Disease Optional

Stroke Optional

Blood Pressure Optional

Diabetes Optional

Kidney Disease Optional

Liver Disease Optional

Depression Optional

Thyroid Optional

Cancer Optional

Other Optional

For Other please specify below Optional

Relative

Father Optional

Mother Optional

Brother Optional

Sister Optional

Grandmother Optional

Grandfather Optional

Extended Family member (Aunt/Uncle/Cousin) Optional

Allergies

Please record any allergies or sensitivities below Optional

Current Medication

Please check and include as much information about your child’s current medication below.

If they have a previous repeat medication list please give this to us and they may need a medication review appointment: Optional

Further Details

Electronic Prescribing

If you would like your child's prescriptions to be sent electronically, please provide details of the pharmacy you would like to use: Optional

Parent or Guardian Signature Optional

Please provide your full name

Sharing Your Childs Health Record

Do you consent to your GP Practice sharing your child's health record with other organisations who care for you?

Yes (recommended)

No – Never

Do you consent to your GP Practice viewing your child's health record from other organisations that care for you?

Yes – (recommended)

Your Childs Summary Care Record (SCR)

Do you consent to your child having an Enhanced Summary Care Record with Additional Information?

Yes – (recommended)

Parent or Guardian Signature

Please provide your full name

Date

Day

Month

Year

Phone Optional

This field is for validation purposes and should be left unchanged.