New Patient Registration (Under 16)

If you are registering a Child Under 5

Please remember to bring in their Red Book on first presentation to the practice!

Why do we need this?

We need this so that we know which immunisations to offer your child, when they are due and if they have missed any as well as to gather information about your Child such as their conditions, allergies and medications if they take any.

Required Information

Select a Surgery to Register

Chiswick Medical Practice

Grove Park Surgery

Wellesley Road Surgery

Name

First Last

Date of Birth

Day

Month

Year

NHS No (if known) Optional

Gender

Female

Male

Unspecified

Email Address

Enter Email Optional Confirm Email Optional

Contact Number Optional

Town & Country of birth:

SMS/Text Consent

We will use this to send appointment reminders and health promotion details. Please tick here if you do not wish to receive messages from us Optional

Current Address

Street Address Address Line 2 City Postcode

Previous Address

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

If from abroad, the date of entry to the UK

Day Optional

Month Optional

Year Optional

Previous GP (name of doctor and/or surgery name) Optional

Has the child lived outside the UK?

Yes

Date of leaving the UK

Day

Month

Year

Date of return

Day

Month

Year

About You (Parent or Guardian)

Name of adult registering the child

First Optional Last Optional

Relationship to Child Optional

Are you registered or registering at this practice?

Yes Optional

No Optional

Parent/Guardian's Full Address

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

How would you like us to contact you about your child? Optional

Who has legal parental responsibility? Optional

Please specify

Contact Number

Do you consent to be contacted by SMS?

Yes

Enter Email Confirm Email

Do you consent to be contacted by email?

Yes

Next of Kin / Name of person(s) with legal parental responsibility

Name

First Optional Last Optional

Contact Number: Optional

Date of Birth

Day

Month

Year

Gender

Male Optional

Female Optional

Other Optional

Relationship to child Optional

Name of school/nursery attended Optional

Is your child home educated?

Yes Optional

No Optional

Please list other residents at your home. Are they registered with us? Optional

Please state name, relationship to child & if they are registered with us

Private Caring Arrangements

Is your child being looked after by a friend, neighbour in their home?

Yes Optional

No Optional

Is this a private fostering arrangement?

Yes

Unsure

Please ask reception if you are unsure

If yes, how long have they been living there?

Is someone looking after your child at home?

Yes

Please let us know if a family member, friend or neighbour helps to look after your child.

Carer’s Name

First Optional Last Optional

Carer’s Contact Number Optional

Carer’s Address

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

Relationship to you Optional

Please tick if your child is currently

Homeless Optional

A refugee Optional

An asylum seeker Optional

Is your child currently housebound?

Yes Optional

No Optional

If housebound, please provide details:

Is the child a ‘child looked after’ under the care of the local authority?

Yes Optional

No Optional

Name of responsible Local Authority

Name of social worker

First Last

Name of Foster Carer

First Last

If Child ‘looked after’ Delegated Authority documentation needs to be shared with practice

Share details with practice

Is your child or family currently involved with Children’s Social services or have they ever been known to Children’s Social services or the safeguarding team?

Yes Optional

No Optional

Name of social worker

First Last

Please give further details.

Your Child’s Background Information. Due to government policy, we are obliged to ask you the following:

Your Child’s Ethnic Origin Optional

Please specify

What is your childs main spoken language?

Do you need an interpreter?

Yes

Communication Needs

Does your child have any communication needs?

Yes

Please specify

Hearing aid

Lip reading

Large print

Braille

British Sign Language

Makaton Sign Language

Guide dog

Other

Looking after a family member/carer

Please let us know if your child is looking after someone who is ill, frail, disabled, has mental health/emotional support needs, or substance misuse.

Is your child looking after someone at home?

Yes Optional

No Optional

Who is your child looking after?

Do you think they would like additional support as a young carer?

First Choice

Second Choice

Third Choice

Is your child known to services such as young carers?

Yes

Your Child’s Medical Background

Please give information about any serious illnesses, operations, or injuries your child has had in the past? Optional

Please state the condition, year diagnosed and if it is ongoing

Is your child registered with a dentist?

Yes Optional

No Optional

To find a dentist visit NHS Choices www.nhs.uk

Please provide details of any medication your child takes (including the contraceptive pill): Optional

Please state the name of medication, dosage & frequency

Please give details of any allergies or sensitivities your child may have to medication/food Optional

Family History

Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent.

Medical problem

Asthma Optional

COPD Optional

Epilepsy Optional

Heart Disease Optional

Stroke Optional

Blood Pressure Optional

Diabetes Optional

Kidney Disease Optional

Liver Disease Optional

Depression Optional

Thyroid Optional

Cancer Optional

Other Optional

For Other please specify below Optional

Relative

Father Optional

Mother Optional

Brother Optional

Sister Optional

Grandmother Optional

Grandfather Optional

Extended Family member (Aunt/Uncle/Cousin) Optional

Immunisation History

Which vaccinations has your child had? Optional

Please indicate the date (DD/MM/YY), GP Surgery & if it was done private or abroad.

Your Child’s Pharmacy Services

Prescriptions for your child can be sent electronically to a pharmacy. Please provide the name and postcode of the pharmacy you would like to use for your child. Optional

Sharing your child’s medical record

Medical Record Sharing allows your child’s complete GP medical record to be made available to authorised healthcare professionals involved in their care. You will always be asked your permission before anybody looks at your child’s shared medical record.

I do not want to share my child’s GP record locally Optional

Summary Care Records contains details of your child’s key health information – medications, allergies and adverse reactions. They are accessible to authorised healthcare staff in A&E Departments throughout England. You will always be asked your permission before anybody looks at your child’s Summary Care Record.

I do not want your child to have a Summary Care Record Optional

The Integrated Care Programme Collates information about your child and the care they receive. It links information from all the different places where your child receives care, such as their GP, hospital and community services, to help them provide a full picture of your child’s medical needs and the care they are receiving. This data is made available to NHS Commissioners so that they can design integrated services and is shared with third parties for research purposes.

I wish to OPT OUT from my child’s Personal Confidential Data being shared outside their GP practice Optional

Parent/Guardian permission given

Permission given for someone other than a Parent/Guardian to accompany your child to an appointment? E.g. Grandparent, Nanny, childminder

Yes Optional

No Optional

Name of person(s):

First Optional Last Optional

Thank you for completing this form

Please see our practice leaflet/website for further information about our team/services.

Email Optional

This field is for validation purposes and should be left unchanged.

If you are registering a Child Under 5

Why do we need this?

Required Information

About You (Parent or Guardian)

Next of Kin / Name of person(s) with legal parental responsibility

Private Caring Arrangements

Your Child’s Background Information. Due to government policy, we are obliged to ask you the following:

Communication Needs

Looking after a family member/carer

Your Child’s Medical Background

Family History

Immunisation History

Your Child’s Pharmacy Services

Sharing your child’s medical record

Parent/Guardian permission given

Chiswick Medical Practice

Main Site

Branch Sites

Chiswick Health Centre Site (previously Chiswick Family Doctors Practice)

Wellesley Road Site
(previously Wellesley Road Practice)

If you are registering a Child Under 5

Why do we need this?

Required Information

About You (Parent or Guardian)

Next of Kin / Name of person(s) with legal parental responsibility

Private Caring Arrangements

Your Child’s Background Information. Due to government policy, we are obliged to ask you the following:

Communication Needs

Looking after a family member/carer

Your Child’s Medical Background

Family History

Immunisation History

Your Child’s Pharmacy Services

Sharing your child’s medical record

Parent/Guardian permission given

Main Site

Branch Sites

Chiswick Health Centre Site (previously Chiswick Family Doctors Practice)

Wellesley Road Site (previously Wellesley Road Practice)

Wellesley Road Site
(previously Wellesley Road Practice)