New Patient Registration Form – Children under 16 years Step 1 of 2 50% GMS1 New Patient Registration FormNHS Number Title(Required)Please SelectMrMrsMissMsDrOtherFirst Names(Required) Surname(Required) Previous Surname Date of Birth(Required) Day Month Year Gender(Required) Male Female Ethnic Origin(Required) White - British White - Irish Other White Mixed - White and black Caribbean Mixed - White and black African Mixed - White and Asian Other mixed Asian/British Asian - Indian Asian/British Asian - Pakistani Asian/British Asian - Bangladeshi Other Asian Black British - Caribbean Black British - African Other black Chinese Any other Not Stated Please Specifiy(Required) Town and Country of Birth(Required) Address(Required) Street Address Address Line 2 City Postcode Main Contact Number(Required)Email Enter Email Confirm Email Please help us trace your previous medical records by providing the following information:Your previous address in the UK Street Address Address Line 2 City County Postcode Name of previous GP Surgery(Required) Address of previous GP Surgery(Required) Street Address Address Line 2 City County Postcode If you are from abroad:Your first address where registered with a GP Street Address Address Line 2 City County Postcode If previously resident in UK, date of leaving Day Month Year Date you first came to live in the UK Day Month Year New Patient Health QuestionnaireFull Name(Required) Gender(Required) Male Female Address(Required) Street Address Address Line 2 City Postcode Who else lives in this household? Mum Dad Step parent Parent’s partner Grandparents Brothers and sisters Foster carer Guardian Others- please state How many brothers/sisters? Please state others: Mobile NumberHome NumberEmail Who do these contact details belong to, e.g mum, dad etc.. Can we leave messages regarding your child on these contact numbers?(Required) Yes No Would you like to register with the Practice for SMS text message reminders?(Required) Yes No WHO HAS PARENTAL RESPONSIBILITY FOR THIS CHILD? Please tell us their name, contact details (if not given above) and their relationship to the childPlace of Birth(Required) Do you need an interpreter?(Required) Yes No Which Language?(Required) Ethnic Origin White - British White - Irish Other White Mixed - White and black Caribbean Mixed - White and black African Mixed - White and Asian Other mixed Asian/British Asian - Indian Asian/British Asian - Pakistani Asian/British Asian - Bangladeshi Other Asian Black British - Caribbean Black British - African Other black Chinese Any other Not Stated Other DOES YOUR CHILD HAVE A DISABLITY OR CHRONIC CONDITION?HAS YOUR CHILD HAD ANY SERIOUS ILLNESSES OR OPERATIONS?IS YOUR CHILD ALLERGIC TO ANYTHING?IS YOUR CHILD ON ANY REGULAR MEDICATION?Which school or nursery does your child attend? 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)A hospital specialist?(Required) Yes No A health visitor?(Required) Yes No A social worker?(Required) Yes No Any other health professionals?(Required) Yes No Additional NotesHas your child ever been under a Child Protection Plan?(Required) Yes No ImmunisationsIt 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 2nd Diphtheria, Tetanus, Whooping Cough, Polio, Hib, rotavirus* age 3m 3rd Diphtheria, Tetanus, Whooping Cough, Polio, Hib age 4m 1st Pneumococcal age 2m 2nd Pneumococcal age 4m 1st Meningitis C age 3m Hib/ Meningitis C age 12-13m 1st Measles, Mumps, Rubella (MMR) age 12-13m Booster Pneumococcal age 12-13m Booster Diphtheria, Tetanus, Whooping Cough, Polio age 3y 4m Booster Measles, Mumps, Rubella (MMR) age 3y 4m Details of any other immunisations: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.