Child New Patient Registration

Once you have completed the form you will need to come into the practice with two forms of ID, one proof of address and one photographic to complete your registration.

To register a new patient you will need to live within our practice boundary.

Child Registration

Child Registration

Child's Personal Details

Title: *
Gender: *
Please use date format DD/MM/YYYY.
e.e Parent, Guardian, Child etc

Note, we use the mobile number for text messages. Text messages will automatically cease when the Child is 11 years old.

Has Legal/Parental Responsibility? *
Next of Kin?
Does the child have any special communication/mobility needs? *
Please Specify:
Is the child currently:
Is the child in care?
Is the child a 'Looked After Child'?
In what capacity? *
Is the child home educated? *
Has the child or family either currently or in the past been known to Children’s Services? *

Required Information:

Is your child looking after someone at home? *

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

Do you think the child would like additional support as a young carer?
Is the child known to services such as Young Carers?
Is the child being privately fostered (see definition below)? *
Are children's services aware?

Private fostering is an arrangement whereby a child under the age of 16 (or 18 if the child has a disability) (S.66 Children Act 1989) is placed for 28 days or more in the care of someone who is not the child’s parent(s) or a ‘connected person’. Private foster carers can be from the extended family, e.g. a cousin or a great aunt, but cannot be a relative as defined under the Children Act 1989, section 105:‘A relative under the Children Act 1989 is defined as a ‘grandparent, brother, sister, uncle or aunt (whether full blood or half blood or by marriage or civil partnership) or step-parent’.

Please help us trace the child’s previous medical records by providing the following information:

Please include postcode. If you do not have a previous address, please state 'N/A'.
If you do not have a previous GP, please state 'N/A'.
Please include postcode. If you do not have a previous GP, please state 'N/A'.

If you are from abroad:

Please include postcode.

If registering a child under 5:

Supplementary Questions

Anybody in England can register with a GP practice and receive free medical care from that practice.

However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK.

Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.

More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice. Alternatively for more information go to

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.

The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

Please select one of the following statements:

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate
action may be taken against me.

A parent/guardian should complete the form on behalf of a child under 16.

European Economic Area (EEA) Country

For a list of EEA countries visit:
Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?
Do you have a non-UK European Health Insurance Card (EHIC) or a Provisional Replacement Certificate (PRC) ?

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.


Please enter the details from your EHIC or PRC below.

S1 Form

Do you have an S1 Form?
Please give your S1 form to the practice staff.

How will your EHIC/PRC/S1 data be used?

By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process.

Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

Child’s Personal Medical History:

(eg normal, forceps, caesarean)
Has your child ever suffered from any important medical illness, operation or admission to hospital?

Family Medical History:

Have any close relatives (father, mother, sister, brother only) ever suffered from:

Please indicate:

Child's Immunisations

Whooping Cough
Booster: Tetanus
Booster: Diphtheria
Booster: Polio
Booster: MMR

Child’s Allergies:

Please list any allergies the child has to any drugs/medications or if known egg allergy or peanut allergy.

About the Child

Child's Ethnicity: *
Please advise if you feel your child’s religion will affect any treatment received:
Does the child need an interpreter?

Data Sharing Consent Choices:

To maintain continuity of clinical care, we upload certain medical information so that it is available to other healthcare organisations (eg Emergency Departments). Please read the accompanying leaflet which details what part of your record is extracted and how it is used to help other NHS organisations.

Where you have provided information on how to contact you, can you confirm you are happy for the practice to contact you by the following:

By email:

This will be to send you letters, the practice newsletter and the like.

By text:

This will be to send you reminders of appointments via text.

I confirm that the information that has been provided is true to the best of my knowledge.