New Patient Registration - Children

Before new patients can be taken onto our list, registration forms and a patient history form must be completed and you will have to attend the practice for a simple health check.

If this is your first time registering in the UK you should bring with you proof of your eligibility, for example a document bearing your NHS number or, failing that, your passport.

Before any medication can be issued you must be seen by one of the doctors or nurse practitioners.

Please ensure you have read the information in these downloads below completing the online registration form below:

Your Child's Details

First Name Required

Middle Name

Last Name Required

Date of Birth Required

Gender Required

Which of the following best describes how you think of yourself?

Non-binary

Female

Male

Prefer not to say

Unable to answer

Is your gender the same as the sex you were assigned at birth?

Yes

Prefer not to say

Unable to answer

Town and country of birth Required

NHS Number

Address Required

Home Telephone Required

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

Your child's previous address in UK Required

Name of previous GP practice while at that address Required

Address of previous GP practice Required

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If you are from abroad

Your child's first UK address where registered with a GP Required

Date your child first came to live in UK Required

If previously resident in UK, date of leaving

These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.

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If you need your doctor to dispense medicines and appliances*

* Not all doctors are authorised to dispense medicines

Do you live more than 1.6km in a straight line from the nearest chemist

Yes

Would you have serious difficulty in getting them from a chemist

Yes

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NHS Organ Donor registration

Please tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision.

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please select the boxes that apply.

Any of my organs and tissue or

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

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PATIENT DECLARATION for all patients who are not ordinarily resident in the UK

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.

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 Required

I understand that I may need to pay for NHS treatment outside of the GP practice

I understand I have a valid exemption from paying for NHS treatment outside of the GP practice. This includes for example, an EHIC, or payment of the Immigration Health Charge (“the Surcharge”), when accompanied by a valid visa. I can provide documents to

I do not know my chargeable status

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. Required

Yes

Are you:

A refugee

An asylum seeker

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NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), PROVISIONAL REPLACEMENT CERTIFICATE (PRC) DETAILS and S1 FORMS

Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

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.

Do you have a non-UK EHIC or PRC?

Yes

If yes, please enter details from your EHIC or PRC below:

Country Code:

Name

Given Names

Date of Birth

Personal Identification Number

Identification number of the institution

Identification number of the card

Expiry Date

PRC validity period from

PRC validity period to

Do you have an S1 (e.g. you are retiring to the UK or you have been posted here by your employer for work or you live in the UK but work in another EEA member state).

Yes

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.

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Your Child's Registration Information

If other please provide details

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Your Child's Communication Needs

What is your main spoken language?

Do you need an interpreter? Required

Yes

Does your child have any communication difficulties Required

Yes

If Yes please specify below Your communication needs

Hearing aid

Lip reading

Large print

Braille

British Sign Language

Makaton Sign Language

Guide dog

Does your child have a Leaming Disability? Required

Yes

If Yes please request a Learning Disability Screening Tool form

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Your Child's Medical History

Has your child suffered from Asthma? Required

Yes

Has your child suffered from Diabetes? Required

Yes

Has your child suffered from Depression? Required

Yes

Has your child suffered from Epilepsy? Required

Yes

Any other conditions, operations or hospital admission details: Required

If your child is currently under the care of a Hospital or Consultant outside our area, please tell us here: Required

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Your Child's Family History

Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent

Asthma Required

Yes