Child Registration Form

Patient's Details

Title *

Miss

Master

Surname *

First names *

NHS Number

Previous Surnames

Gender *

Male

Female

Town and Country of Birth *

Home Address *

Postcode *

Name of current school

If you are registering a child under 5

Child Surveillance

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

Select a Doctor from the list below

Carers Information

Is your child looking after someone?

Yes

eg. someone who is ill, frail, disabled, has mental health/emotional support issues or substance misuse

Relationship to child *

Does your child have a carer?

Yes

eg. family member, friend or neighbour

Carer's Name *

Carer's Phone Number *

Preferably a mobile number

Carer's Address *

Does your child need help with mobility/hearing/speaking? *

Yes

Please give details: *

eg. Wheelchair, hearing aid, braille, lip reading, sign language etc.

Is your child housebound?

Yes

Ethnic Origin

Please select the ethnic group which you consider your child belongs to *

Is English your child's main spoken language? *

Yes

What is your child's main spoken language? *

Does your child need an interpreter?

Yes

What is your child's religion?

Is your child currently:

Homeless

A refugee

A asylum seeker

Medical Records

Please help us trace your previous medical records by providing as much of the following information as possible.

Child's previous address in UK

Name of previous doctor while at that address

Address of previous doctor

If you are from abroad

Child's first UK address where registered with a GP

If previous resident in UK, date of leaving:

Date child first came to live in UK:

Please state all countries your child has lived in, or visited for longer than 6 months

Please include dates/years.

Online Services

Patient's Details

If you are registering a child under 5

About You (Parent/Guardian)

Carers Information

Ethnic Origin

Medical Records

If you are from abroad

New Patients

Meet the Team

Services

Policies

Day	Reception	Surgery
Monday	08.00 – 19.00	08.30 – 18.30
Tuesday	08.00 – 19.00	08.30 – 18.30
Wednesday	08.00 – 19.00	08.30 – 18.30
Thursday	08.00 – 19.00	08.30 – 18.30
Friday	08.00 – 19.00	08.30 – 18.30
Saturday	08.30 – 12.30	08.30 – 12.30

	On the day	Patients can book an appointment via our Online Services, by calling 020 8630 1601 or in person during opening hours.
	Telephone Consultations	For help and advice, call us on 0208 630 1601 .
	Nurse Appointments	The Practice Nurses can help you with a range of issues from health management to vaccinations.
	Book in Advance	We reserve a few appointments for advance booking. Please phone the practice on 0208 630 1601 for more an appointment.
	Out of Hours	If you have an urgent health problem which cannot wait until the surgery is open please call 0208 630 1600 or call 111.
	Online Services	Patients can book appointments up to 2 weeks in advance and from 8pm the night before using our online booking system.

	Online	You can order your repeat prescriptions via our online services.
	In Person	Fill in a prescription request form or underline the items needed on the tear-off side of your prescription and drop it into the surgery.
	Post	If a stamped addressed envelope is supplied your prescription can be returned via Royal Mail. Find our postal address.
	Pharmacy	You may also arrange for a pharmacy of your choice to collect your prescription on your behalf.