New Patient Registration Form (Child Under 18 Yrs)

THIS FORM IS TO BE PRINTED AND GIVEN TO PARENTS/CARERS TO COMPLETE.
WHEN RETURNED
PLEASE TRANSFER INFORMATION FROM THIS FORM ONTO THE NEW CHILD REGISTRATIONS TEMPLATE
New Patient Registration Form (Child: under 18 years)
Whilst we are waiting for your child’s full medical records from their last doctor, it would help us if you
could take the time to complete this questionnaire so that your child’s care is transferred as seamlessly
as possible. Please bring your child’s red book so we can access information on their immunisations.
1 Your child’s personal details:

Full Name: Date of birth
Gender : Male☐ Female ☐ Unspecified ☐ NHS number
Current Home telephone

address: number
Previous Mobile telephone

address (if you have number
changed address in the
last year) Email:
2 Information about the child’s parents / carers

Are you the child’s biological or birth parent? Yes ☐ No ☐
If no please move to the starred question ** ‘what is your relationship to the child’
Parent 1: Name: Different address? – please
supply
Address – Same as listed above ☐
Parent 2: Name: Different address? – please

supply
Address – Same as listed above ☐
Do both parents have parental responsibility? Yes ☐ No ☐

If no please state who has parental responsibility:
What is parental responsibility?

A mother automatically has parental responsibility for her child from birth.
A father usually has parental responsibility if he’s either (a) married to the child’s mother or (b)
listed on the birth certificate (from 1 December 2003) or (c) getting a parental responsibility agreement with the mother
(d) getting a parental responsibility order from a court
If you are the birth / biological parent please proceed to section 3 – you do not need to complete
the rest of this section.
If the answer to this is no please complete the remainder of this section:
**What is your Adoptive parent ☐ Foster carer ☐Private fostering arrangement ☐ Special
relationship to Guardianship Order ☐ Other☐ (please explain)
Page 1 of 5
the child?
Do you have parental responsibility for the child? Yes ☐ No ☐ If no please state who holds
(see what is parental responsibility above) parental responsibility:
How long have Length of stay:

you been caring Is this longer than 28 days Yes ☐ No ☐
for the child?
Is this child Homeless ☐ A refugee ☐ An asylum seeker ☐
currently :
Yes ☐ No ☐
Is this child a No ☐ Yes ☐
looked after child In what capacity? Temporary ☐ Permanent ☐
under the care of Which local authority?
the local
authority? Name of social worker?
3 Household composition – who else lives in the home? Eg: other family members , lodgers etc
Name What is their relationship to Are they registered at this surgery?
the child?
If required please continue this list at the end of this form and indicate that here Yes ☐ No ☐
Does the child stay at another address regularly? If so what is the relationship to this person?
Yes☐ No ☐
Name Relationship to the child Address
4 Your child’s background information

Your child’s religion Please state:
Your child’s ethnic origin: Please tick one:
Black Caribbean / White (UK) ☐ Indian / British Indian Arabic ☐
English ☐ ☐
Black African / British White (Irish) ☐ Pakistani / British Chinese ☐
☐ Pakistani ☐
Other black White (Other) ☐ Bangladeshi / British Other: (please state) ☐
background ☐ Bangladeshi ☐ ☐
Other mixed background (please state) ☐ Other Asian I do not wish to state my
Background ☐ child’s ethnic group ☐
What is your child’s main spoken language (please state)?
Does your child need Yes ☐ No ☐

an interpreter? Language:
Does your child need help with mobility and communication? Yes ☐ No ☐ If yes please tick all that
apply
Wheelchair ☐ Walking aid (please Hearing aid ☐ British sign language ☐
specify) ☐
Makaton sign Lip reading ☐ Braille ☐ Other ☐
language ☐
Is this child currently Housebound? Yes ☐ No ☐
5 Contact with children’s social care (social services) - Mandatory field

Is your child or family currently receiving support from children’s social care?
No ☐ Yes ☐
Which Local authority?
Name of social worker:
Has your child or family ever received support from children’s social care?
No ☐ Yes ☐
Which Local authority?
Name of social worker:
6 Educational information
For children aged 2-4 is the child at nursery? Name of nursery:
Yes ☐ No ☐
If the child is school aged are they in fulltime Name of school:
education Yes ☐ No ☐
Is the child home educated? Yes ☐ No ☐ Is the local authority aware?
Yes ☐ No ☐
7 Children looking after a family member

Does your child look after someone at home? Yes ☐ No ☐ If so who?
(If no please proceed to section 8)
If so do you think they would like additional support as a
young carer? Yes ☐ No ☐
Is your child known to services such as young carers?
Yes ☐ No ☐
Past medical History and allergy status

8 Please give information about any serious illnesses, operations, disabilities or injuries your child have
or has had in the past?
Condition Year diagnosed Ongoing? Yes / No
Is your child currently or previously under Paediatrics / child and adolescent mental health team /
speech and language therapy? Yes ☐ No ☐
If yes please state which and why:
Does your child have an educational Health care plan (EHCP) Yes ☐ No ☐
Please provide details of any medication you child takes (including the contraceptive pill)
Name Dosage Frequency
Please give details of any allergies your child has to medication or food: Yes☐ No ☐
Details:
Family History: please let us know of any of the following conditions that have affected your child’s
parents/ brothers / sisters
* Heart disease * Asthma * Mental Health * Stroke (CVA)
UNDER the age of problems (e.g.
60 Depression)
* Cancer * Diabetes * Sudden death * Epilepsy

under the age of
40
9 Your child’s online access

You are now able to book appointments and order repeat medications for your child online
Would you like to register for online services? Yes ☐ No ☐
1 Your signature
0 Parent/guardian signature Date:

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THIS FORM IS TO BE PRINTED AND GIVEN TO PARENTS/CARERS TO COMPLETE.

1 Your child’s personal details:

Gender : Male☐ Female ☐ Unspecified ☐ NHS number

Current Home telephone

Previous Mobile telephone

2 Information about the child’s parents / carers

Address – Same as listed above ☐

Parent 2: Name: Different address? – please

Address – Same as listed above ☐

Do both parents have parental responsibility? Yes ☐ No ☐

What is parental responsibility?

How long have Length of stay:

4 Your child’s background information

Does your child need Yes ☐ No ☐

5 Contact with children’s social care (social services) - Mandatory field

7 Children looking after a family member

Past medical History and allergy status

* Cancer * Diabetes * Sudden death * Epilepsy

9 Your child’s online access

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