Fill this form if the applicant is under 14 years of age

Personal Details
Surname Title
Forename(s) Gender
Previous Surname Date of Birth
Town of Birth NHS No:
Your Current Address and Contact Information
House name or No Phone
Street Parent's Mobile Phone No
Location
Town

Do you wish to receive Appointment reminders by text to
County your mobile phone?
Post Code  
Your Previous UK Address and GP
Help us trace your medical records by providing details of your previous UK address and doctor.
Previous UK Address

Name and Address of GP
If you are from abroad
Your first UK address where registered with a GP
If previously resident in UK, Date of leaving
Date you first came to live in UK    
If the family is returning from the Armed Forces
Address before enlisting
If you are registering a child under 5
I wish the child above to be registered for Child Health Surveillance
If you need your Doctor to dispense medicines and appliances
I live more than 1 mile in a straight line from the nearest chemist
I would have serious difficulty in getting them from a chemist
Not all doctors are authorised to dispense medicines
NHS Organ Donor registration
I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply.
Any Organ   Kidneys   Heart   Liver   Corneas   Lungs   Pancreas
 For more information, please ask at reception for information leaflet or visit the website www.uktransplant.org.uk or call 0845 60 60 400
Next of Kin
Name
Address
Phone
Relationship
Ethnicity
We are required to record information regarding your ethnic origin. Please tick the appropriate box (you may refuse this information if you wish).
White British or Mixed British
Irish
Other White Background
Mixed White and Black Caribbean
White and Black African
White and Asian
Other Mixed Background
Asian or
Asian British		 Indian or British Indian
Pakistani or British Pakistani
Bangladeshi or British Bangladeshi
Other Asian Background
Black or
Black British		 Caribbean
African
Other Black Background
Other Ethnic Group Chinese
Other
Not Stated or
Patient Refused		 Ethnic Category not stated
Patient Refused
New Patient Questionnaire (for parents of a child under 14 years)
Please complete the details below so we know as much about your child as possible.
Mother's Surname (if different from child)
 		 Father's Surname (if different from child)
 
What injections has your child had, and when?
    Date Date Date Date
Diphtheria
Tetanus
Whooping Cough
Polio
Hib
Pneumococcal  
Meningitis C    
MMR    
Pre-School Booster      
BCG      
I agree that my child named above should continue the Immunisation Program
Has your child had any illnesses?
Asthma Chicken Pox
Eczema Mumps
Tonsillitis Measles
Ear Infections Other (pls specify)
Has your child had any operations?
Is your child allergic to any drugs or dressings?
Are there any inherited conditions in your family that your child suffers from or might suffer from?
What is your child's current state of health?
I confirm that the Information I have given is correct. By submitting this form I agree that my Child will be registered with my new practice as soon as possible on or after the date below without further confirmation. I understand that by registering with this practice my registration with the current doctor will be ended and the records transferred.
     
I want my Child to be registered from this date:

You may be asked to provide evidence of entitlement to NHS care.
Accepted documents are:
European Health Insurance Card (EHIC)
Passport (including Visa for stay in the UK)
NHS Medical Card
Photo Driving Licence
Birth Certificate
Marriage Certificate
National Insurance Number Card
Evidence of benefit entitlement
Wage slip with employer's details