New Patients

Select your practice

Are you completing this form for a child under 16 years old? *

No

Yes

Complete the registration form below with the details of the child

Title *

First name *

Middle name(s)

Surname *

Previous surname(s)

Date of birth *

NHS number (optional)

Sex at birth *

Please select your sex as recorded at birth.

Gender *

Please select the gender that you most identify with.

Other (please specify the term you use to describe your gender) *

Religion

Ethnicity *

Other (Please specify)

Language Support

What is your main spoken language? *

Do you need an interpreter?

Yes

No

Do you use any of the following?

Sign Language

Hearing Aid

Lip Reading

Contact Details

Current home address (first line)

Current home postcode *

Have you lived at your current home address for more than 3 years?

Yes

No

Previous home address (first line)

Previous home postcode

Mobile number *

Home Number

Your email address

Have you previously been registered with an NHS GP?

Yes

No

Please provide the name and address of your previous GP *

Were you born in the UK

Yes

No

Select country of birth

England

Wales

Scotland

N.Ireland

Please provide the most recent address from the above selected country

UK entry date *

Country of birth *

Place of birth (e.g. town or city) *

Have you previously served in the armed forces?

Yes

No

Date of enlistment *

Date of leaving *

Next of Kin

Full name

Contact number

Please provide a contact number. We will only contact your next of kin in an emergency situation

Relationship

Other (please specify)

Child Under 16 Registration

Protection Plan/Foster Care Information

Is the child subject to a child protection plan?

Yes

No

Is the child in

Foster care

Private foster

None of the above

If you are registering a child under 5, do you wish for the child to be registered with a doctor for Child Health Surveillance?

Yes

No

Parents/Carer Details

Mother/Carer

Carer First Name

Carer Surname

Contact number

Father/Other Carer

Carer First Name

Carer Surname

Contact number

Child's School Details

School name

School telephone number

School address

Please advise if the child has had any of the following immunisations (you can check your child's red book).

Age due: 8 weeks

DTaP/IPV/Hib/HepB (Diphtheria, tetanus, pertussis (whooping cough), polio, Haemophilus influenzae type b (Hib), and hepatitis B)

Yes

No

Don't know

Date of Immunisation

PCV (Pneumococcal conjugate vaccine)

Yes

No

Don't know

Date of Immunisation

MenB (Meningococcal group B)

Yes

No

Don't know

Date of Immunisation

Rotavirus (Rotavirus gastroenteritis)

Yes

No

Don't know

Date of Immunisation

Age due: 12 weeks

DTaP/IPV/Hib/HepB (Diphtheria, tetanus, pertussis, polio, Hib, and hepatitis B)

Yes

No

Don't know

Date of Immunisation

Rotavirus

Yes

No

Don't know

Date of Immunisation

Age due: 16 weeks

DTaP/IPV/Hib/HepB (Diphtheria, tetanus, pertussis, polio, and Hib, and hepatitis B)

Yes

No

Don't know

Date of Immunisation

PCV (Pneumococcal conjugate vaccine)

Yes

No

Don't know

Date of Immunisation

MenB (Meningococcal group B)

Yes

No

Don't know

Date of Immunisation

Age due: 12 months

Hib/MenC

Yes

No

Don't know

Date of Immunisation

PCV (Pneumococcal conjugate vaccine)

Yes

No

Don't know

Date of Immunisation

MMR (Measles, mumps, and rubella (German measles))

Yes

No

Don't know

Date of Immunisation

MenB (MenB booster)

Yes

No

Don't know

Date of Immunisation

Age due: 3 years 4 months old or soon after

DTaP/IPV (Diphtheria, tetanus, pertussis, and polio)

Yes

No

Don't know

Date of Immunisation

Second MMR (Measles, mumps, and rubella) - please note this may have been given at 15 months or thereafter

Yes

No

Don't know

Date of Immunisation

Our ethos is to keep people healthy through screening and immunisation programmes. We actively encourage your child to follow the routine immunisation schedule.

Your Information

We would like to send you text messages to your registered mobile about your healthcare. This may include things like appointment reminders and test results. Is this OK?

Yes

No

Would you like us to send you appropriate emails from the surgery?

Yes

No

Summary Care Record
A summary care record (SCR) is an electronic summary of key health information. It will hold limited essential information derived initially from your GP record. This will include medication, adverse reactions and allergies. If you wish to know more information regarding the system and the benefits please ask reception. Alternatively, visit the website: www.nhscarerecords.nhs.uk or call 0845 603 8510

Would you like to

Opt in

Opt out

Are you happy for us to share your full medical records electronically with other services involved in your care?

Yes

No

How did you hear about us? *

Other (Please specify)

Patient Signature

Clear

Text

We use secure, NHS approved software to provide video consultations safely and effectively for our patients.

Contact Us

Hickings Lane Medical Centre

New Patients Welcome