New Patient Registration Under 18

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All questions marked with a * are mandatory

Child's Details
Child's Title: *
 
Including middle names
Is the child younger than 42 days (6 weeks)?: *
 
Child's Gender at birth: *
Do they identify differently?:
UK Mobile only
Are you happy for us to contact you by email?:
Are you happy for us to contact you by text message? : *
 
Do you have or do you want to nominate a pharmacy for electronic prescribing?:
Nominate a pharmacy means we can send any prescriptions directly to the pharmacy without you needing to come to the surgery
include the full address and post code of your chosen pharmacy
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NHS

Your NHS Number

Help us to help you

Providing this reduces the time it takes to process your registration. It helps us get you registered quicker.

  How to find your NHS Number

Help us to help you.

 

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Ethnicity & Religion
Does your child require an interpreter when you see the doctor/nurse?:
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Legal Guardian

The following questions are about the details of the Legal Guardian (i.e. Main Parent, Guardian or Carer) for  

Is the legal guardian registered at this practice?: *

Children cannot be registered unless their legal guardian is a patient at this practice, or unless they are planning to register at the same time.

You cannot continue with this application: *
Legal Guardian's Details
Legal Guardian's Title: *
Legal Guardian's Gender: *
 
 

You will be required to include copy of the Birth Certificate as proof later in this form.

please name all the people who live in the household with the child, and the relationship to the child.
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Previous Details
Are you registering for the first time in the UK? : *
Have you recently moved to the UK: *
Please include postcode
Are you returning from abroad?: *
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Carers

A carer is anyone, including children and adults who looks after a family member, partner, or friend who needs help because of their illness, frailty, disability, a mental health problem or an addiction and cannot cope without their support.

  • This does not mean your normal parenting duties for your child
Does your child have a carer?: *
UK number only
If a company of organisation, please indicate which above.
Do you give us permission to discuss your Child's medical record with their carer?: *: *
Does you child care for someone?: *
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Allergies
Does your child have any allergies?: *
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Lifestyle

Child's Height

What unit of measurement are you using?: *
Conversion from Feet & Inches to Centimetres

Child's Weight

What unit of measurement are you using?: *
Conversion from Stones & Pounds to Kilograms
Child's Smoking Status
Please choose from one of the following options: *
stop smoking

Steps to quit smoking

Stopping smoking lets you breathe more easily. People breathe more easily and cough less when they give up smoking because their lung capacity improves by up to 10% within 9 months.

  NHS Stop Smoking Services

  Take steps now to stop smoking

  10 self-help tips to stop smoking

Are they interested in advice on how to quit?: *
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Child's Personal Alcohol Consumption

What does 1 unit of alcohol look like?

Each of the examples depicts 1 unit of alcohol based on the Alcohol by Volume (ABV) against the Volume (ml) displayed.

Click here for NHS guidance about calculating alcohol units

  • Cider

    Cider 218ml

    Standard 4.5% ABV

  • Wine

    Wine 76ml

    Standard 13% ABV

  • Whisky

    Whisky 25ml

    Standard 40% ABV

  • Beer

    Beer 250ml

    Standard 4% ABV

  • Alcopop

    Alcopop 250ml

    Standard 4% ABV

How often did you have a drink containing alcohol in the past year?: *
 
How many drinks containing alcohol did you have on a typical day when you were drinking in the past year?: *
How often did you have six or more drinks on one occasion in the past year?: *
Child's Personal Alcohol Consumption - Part 2
How often during the last year have you found that you were not able to stop drinking once you had started?: *
How often during the last year have you failed to do what was normally expected from you because of your drinking?: *
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?: *
How often during the last year have you had a feeling of guilt or remorse after drinking?: *
How often during the last year have you been unable to remember what happened the night before because you had been drinking?: *
Have you or somebody else been injured as a result of your drinking?: *
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?: *
 
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Audit Score Result 0 - 7 (Lower Risk)

Lower Risk 

, you have a score of 

Your answers suggest you are at a lower risk of being dependent on alcohol.

  • If you are drinking less than 14 units of alcohol per week, then your drinking is within the UK Chief Medical Officers' low risk drinking guidelines.

Caution advised

If you are drinking regularly at or above the low risk guidelines of 14 units a week, or, you are drinking six or more units if you are female or eight or more units  if you are male in one single session (binge drinking), please consider the increased serious risks to your health being caused by your current drinking pattern.

Audit Score Result 8 - 15 (Increasing Risk)

Increasing Risk

, you have a score of 

Your answers suggest you are at an increasing risk of being dependent on alcohol.

Caution

  • Your drinking is dangerous to your health, increasing your risk of serious health problems including seven types of cancer, liver and heart disease, and high blood pressure.
  • Unless you cut down you are at risk of damaging your health.
Audit Score Result 16 - 19 (Higher Risk)

Higher Risk

, you have a score of 

Your answers suggest you are at Higher Risk of being dependent on alcohol.

Your drinking is dangerous to your health.

  • You are drinking far more than the UK Chief Medical Officers' low risk drinking guidelines of 14 units a week.
  • Regularly drinking this much causes a range of serious health harms including seven types of cancer, liver disease and high blood pressure.
Audit Score Result 20+ (Possible Dependence)

Possible Dependence

, you have a score of 

Your answers suggest you are at High Risk of being dependent on alcohol.

  • Your drinking is dangerous to your health.
  • You are drinking far more than the UK Chief Medical Officers' low risk drinking guidelines of 14 units a week.
  • Regularly drinking this much causes a range of serious health harms including seven types of cancer, liver disease and high blood pressure.

Alcohol Support

If you have become dependant on alcohol, you will have found it difficult to fully control your drinking in some way. So you'll probably need some help either to cut down and control your drinking or stop completely, and also some plans to maintain the improvement after that.

  Find Alcohol Support Services in your area

  Tips on cutting down

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Immunisation History

Please upload any records about vaccinations/immunisations/injections

  • You can upload a document, photo or scan of their redbook or vaccination book
  • It doesn't matter what language it is in, we can get it translated!
  • We will check if your child is due any additional/missing vaccinations and call you to book them an appointment with a nurse
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
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Medical History of your Child
Please include dates.
Please include dates.
Please include dates.
Please make sure you have a month’s supply from your previous practice and please arrange to make an appointment with your new doctor to review your ongoing medication.
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School
Is the child attending school?: *
Social Services
Does the child/family have any contact with a social worker or any other social services?: *

We may contact you to discuss this matter in more detail for Safeguarding purposes

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Summary Care Record

Summary Care Record (SCR)

The Summary Care Record (SCR) system is designed to help both your GP and any emergency staff you contact when the surgery is closed to treat your health needs more efficiently.

  • Your information will be shared between your GP practice, our local hospital and Out Of Hours service.
  • This will enable your GP surgery to access results and any visits you have at the hospital quickly and efficiently, but it also means that if you have an emergency and contact the Out Of Hours service or visit A&E they will have access to your current medications as well as allergies and are better able to treat you.
SCR Options: *
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Application For Online Access
Would you like to apply for online access?: *

Thank you, a member of our team will be in contact in regard to your application for online access.

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Document Uploads

Please upload a copy of the following documents

  • You can upload a document, photo or scan
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
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What happens to this information?

  • Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.
  • We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.
  • To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

You are signing this as   the of  

You are signing this as   the legal guardian of  

  • You have listed the reason for being the legal guardian as: 
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Privacy Consent

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