Child New Patient Information Record

Please complete as many questions as you can about your child. The information will help the practice to provide better medical care for your family.

Parent/Guardian Details

Please state your relationship with the child you are registering to the surgery. *

Parent

Guardian

Foster Carer

Other Carer

Full Name of Parent(s)/Guardian(s) *

Parent(s)/Guardian(s) Contact Number *

Child Details

Full Name *

Date of Birth *

Sex *

Male

Female

Address (including post code) *

Home Tel

Mobile Tel

Children under 5yrs

Name of Child's previous Doctor

Child's previous Home Address

Ethnic Category

Child Medication

If your child takes regular medication, please bring in a copy of the repeat prescription from your previous surgery at your earliest convenience. This will ensure your child receives the correct medication and dosage. *

My child does take regular medication, I have acknowledged the above statement and will action as requested.

My child does not take regular medication.

Medical Questions

Does your child suffer with or had any medical conditions? *

Yes No

If YES, please state below.

Does your child have any allergies? *

Yes No

If YES, please state below.

Vaccination Record

Has your child had any of the following vaccinations: if unsure, please bring in child's health record or Red Book so we can take a photocopy.

Child's 2-month vaccinations: What was given & date given (if you are unsure, please type in the box 'unsure'). *

Child's 3-month vaccinations: What was given & date given (if you are unsure, please type in the box 'unsure'). *

Child's 4-month vaccinations: What was given & date given (if you are unsure, please type in the box 'unsure'). *

Child's 12-13 month vaccinations: What was given & date given (if you are unsure, please type in the box 'unsure'). *

Pre-School vaccinations: What was given & date given (if you are unsure, please type in the box 'unsure'). *

1st, 2nd, 3rd HPV vaccinations: If your child has received this, please state what date all 3 vaccines where given (if you are unsure, please type in the box 'unsure' or type 'not appropriate'). *

School Leavers vaccinations: What was given & date given (if you are unsure, please type in the box 'unsure' or type 'not appropriate'). *

BCG vaccination: If your child has received this, please state what date given (if you are unsure, please type in the box 'unsure' or type 'not appropriate'). *

Other vaccinations: What was given & date given (if you are unsure, please type in the box 'unsure'). *

Summary Care Record

Summary Care Record (SCR). The idea of the SCR is that basic health information about you personally is available electronically across health settings. So, if you found yourself unconscious in an A&E department, for example, the doctors there would be able to see any medication, allergies or medical conditions which might be crucial to them looking after you. Only authorised staff who are directly involved in caring for you can see it. All patients will be automatically opted in to share Medication, allergies, and adverse reactions. For more information about your SCR and how to share additional information visit. www.digital.nhs.uk/summary-care-record or see our website under 'Practice Policies'. *

I acknowledge the information provided. I wish to stay in.

I acknowledge the information provided. I wish to opt out.

If you wish to OPT OUT of sharing your Child's summary care record, please sign with your name below (please do not complete if you wish to STAY IN).

I consent to the practice collecting and storing my data from this form.

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Child New Patient Information Record

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