New Patient Registration Form - Children under 16 years

New Patient Health Questionnaire

Full Name

How many brothers/sisters? Optional

Please state others: Optional

Mobile Number Optional

Home Number Optional

Email Optional

Who do these contact details belong to, e.g mum, dad etc.. Optional

WHO HAS PARENTAL RESPONSIBILITY FOR THIS CHILD? Please tell us their name, contact details (if not given above) and their relationship to the child Optional

Place of Birth

Which Language?

Other Optional

DOES YOUR CHILD HAVE A DISABLITY OR CHRONIC CONDITION? Optional

HAS YOUR CHILD HAD ANY SERIOUS ILLNESSES OR OPERATIONS? Optional

IS YOUR CHILD ALLERGIC TO ANYTHING? Optional

IS YOUR CHILD ON ANY REGULAR MEDICATION? Optional

Which school or nursery does your child attend? Optional

Does your child have contact with any of the following? (if so please can you tell us their names in the additional notes box below)

Additional Notes Optional

Immunisations

It is important that your child’s immunisations are kept up to date. A current photocopy of the immunisation history will help us to maintain their immunisation record; we can take a photocopy of this at reception. If this is not available then please list below.

1st Diphtheria, Tetanus, Whooping Cough, Polio, Hib , rotavirus* age 2m Optional

2nd Diphtheria, Tetanus, Whooping Cough, Polio, Hib, rotavirus* age 3m Optional

3rd Diphtheria, Tetanus, Whooping Cough, Polio, Hib age 4m Optional

1st Pneumococcal age 2m Optional

2nd Pneumococcal age 4m Optional

1st Meningitis C age 3m Optional

Hib/ Meningitis C age 12-13m Optional

1st Measles, Mumps, Rubella (MMR) age 12-13m Optional

Booster Pneumococcal age 12-13m Optional

Booster Diphtheria, Tetanus, Whooping Cough, Polio age 3y 4m Optional

Booster Measles, Mumps, Rubella (MMR) age 3y 4m Optional

Details of any other immunisations: Optional

IMPORTANT: All the information given to the Practice as part of this form will be treated as Confidential. However to give your child the very best health care we work closely with the Health Visiting and School Nursing Service. It is therefore our normal Practice to share the details of all children registering with the Practice with our NHS colleagues in Health Visiting and School Nursing.

New Patient Registration Form – Children under 16 years

GMS1 New Patient Registration Form

Please help us trace your previous medical records by providing the following information:

If you are from abroad:

New Patient Health Questionnaire

Does your child have contact with any of the following? (if so please can you tell us their names in the additional notes box below)

Immunisations