New Patient Registration (Under 16s)

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Please complete our online form

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Please bring the child’s Red Book with you so we can take a copy of their immunisation record.

Child's Personal Details

Title:

Gender:

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Parent / Carer Details

Has Legal / Parental Responsibility?:

Next Of Kin?:

Has Legal / Parental Responsibility?:

Next Of Kin?:

Does the child have any special communication / mobility needs? : *

If yes:

Is the child currently:

Is the child a child in care? :

Is the child a “Looked After Child”?:

Is the child home educated?:

Has the child or family either currently or in the past been known to Children’s Services?:

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Required Information

Is your child looking after someone at home?: *

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?: *

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’.

Are children’s services aware?: *

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

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If you are from abroad

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If registering a child under 5:

If you need your doctor to dispense medicines and appliances

For Dispensing Practices only

Patient Declaration for all patients who are not ordinarily resident in the UK

Patient’s Details

Title:

Gender:

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Child’s Personal Medical History

Has your child ever suffered from any important medical illness, operation or admission to hospital? If so please enter details below

Ongoing:

Family Medical History

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

At the time of diagnosis they were:

Child’s Immunisations

Please provide details of your child’s immunisations with dates if possible (under 5’s). If possible please give your Red Book to Reception to photocopy

Child’s List of Current Medication

Child’s Allergies

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

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Other Details

Child’s Ethnicity:

Please advise if you feel your child’s religion will affect any treatment received:

Does the child need an interpreter?:

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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.

If you wish to OPT OUT please complete the form found with this leaflet.

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):

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Signatures

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

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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New Patient Registration (Under 16s)

Please complete our online form

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CHEADLE HULME

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