New patient registration (under 13)

Would you like a new patient health check for your child?

Yes

No

Patient’s Details

Please specify:

Surname: *

First Name(s) *

Middle Name(s):

Preferred Name:

Gender *

Male

Female

Indeterminate

NHS Number (if known):

Town and Country of birth: *

Home Address: *

Postcode: *

Do either of the parents serve in the Armed Forces?

Yes

No

Please specify:

1st Parent or Guardian

Full Name: *

Date of birth:

Relationship to child: *

Address and postcode:

Home Phone Number:

Mobile Phone Number:

This must not be a shared number

Does this person have parental responsibility?

Yes

No

You will need to provide original birth certificate or a court order to confirm

2nd Parent or Guardian

Full Name:

Date of birth:

Relationship to child:

Address and postcode:

Home Phone Number:

Mobile Phone Number:

This must not be a shared number

Email Address:

This must not be a shared email

Does this person have parental responsibility?

Yes

No

You will need to provide original birth certificate or a court order to confirm

Next of Kin

Full Name:

Phone Number:

Date of birth:

Relationship to child:

SMS and Email Messaging

We offer an extra service of SMS Messaging and emailing to patients. This is used to confirm appointments, to send messages about test results, inform you of upcoming health campaigns etc.

It should be understood that these are not secure methods of communication.

The only secure methods of communication are through Airmid or the NHS App as they allow two factor authentication.

If you are happy to communicate with us, there are certain conditions attached to use of the service.

Please read the statement below and should you wish to register for SMS messaging or emailing, provide your consent on each question:

I confirm that the telephone number given is my personal mobile and not a shared with any other person.
I consent to the Practice contacting me by text message for the purposes of appointment reminders, action needed following test results, health promotion and Practice updates.
It is my responsibility to keep the Practice updated with any changes to my mobile number and or email address.
I acknowledge that appointment reminders, appointment invitations and messages about test results are an additional service and that they may not be sent on all occasions. The responsibility for attending and cancelling appointments as well as contacting the Practice to obtain the results of recent tests still rest with me.
I can cancel the text message facility at any time. My number and email address will be used only for information about me – and not other family members.
Text messages and emails are generated using a secure facility, but I understand that they are transmitted over a public network onto a personal telephone and as such, may not be secure.

Can we leave messages on your phone?

Yes

No

Can we contact you by text?

Yes

No

Can we contact you by email?

Yes

No

Ethnicity

Please state:

Do you speak English?

Yes

No

Do you read English?

Yes

No

First Spoken Language:

Allergies

Does your child have any allergies?

Yes

No

Please specify what they are allergic to, what happens and when they had their first reaction:

Medication

Current Medication:

Does your child take any medication prescribed by a hospital?

Yes

No

Please specify the medication prescribed by a hospital:

Does your child take any over the counter medication?

Yes

No

Please specify the over the counter medication:

Tell us whether you accept cookies

New patient registration (under 13)

Patient’s Details

1st Parent or Guardian

2nd Parent or Guardian

Next of Kin

SMS and Email Messaging

Ethnicity

Allergies

Medication