Child Under 18 Registration Form

Patients Details

Please fill in your details accurately

Name *

Date of Birth *

Child's phone number (if over the age of 12)

Mother's Name and Telephone Number *

Mother's Address (if different from child's)

Father's Name and Telephone Number *

Father's Address (if different from child's)

Birth Town *

Birth Country *

If born abroad, date of entering the UK (N/A if born in UK)

NHS number

Sex *

Male

Female

Address *

Postcode *

Landline

Next of Kin (Emergency Contact)

Next of Kin's Name *

Next of Kin's Address (if different from above)

Next of Kin's Telephone Number *

Other Information

What type of house does the child live in? *

Privately Owned

Rented Property

Council Owned

Is it a house or flat (if flat which floor)? *

Are there any housing problems? (e.g. overcrowding, damp etc) *

Please list all the people (children and adults) that share the house with the child and their relationship to the child.

Immunisations

Please enter the exact dates of your child's immunisations.

Tetanus

Polio

Diptheria

Whooping Cough (Pertussis)

HIB

Pneumoccal

Hepatitis B

Rotavirus

Meningitis B

MMR

Meningitis C

Summary Care Record

NHS healthcare staff caring for you may not be aware of your current medications, allergies you suffer from and any bad reactions to medicines you have had, in order to treat you safely in an emergency. Your records will stay as they are now with information being shared by letter, email, fax or phone. If you have any questions, or if you want to discuss your choices, please contact your GP practice.

Complete Registration

Please complete this section below.

If you are registering a child under 5

I wish the child above to be registered with the named doctor for Child Health Surveillance

If you need your doctor to dispense medicines and appliances

I live more than 1 mile in a straight line from the nearest chemist

I would have serious difficulty in getting them from a chemist

Signature

Signature of patient

Signature on behalf of patient

Signed

Date

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