Victoria Road Surgery

New Patient Registration – Child

Everyone is welcome in general practice.

Note: You need to provide proof of ID, address, immigration status or an NHS number in order to receive care or see a GP. Without NHS number we cannot proceed with the registration.

To access our services, you will need to be registered as a patient with us.

The registration process is quick and easy. Fill out the form and our admin team will process your registration.

Note: We are only accepting new patients in the B27 area

  • Background details
  • Other Information
  • Communication
  • Family History
  • Patient Declaration

Your child details

Gender

Parent or guardian details

Mobile telephone : do you give consent to be contacted by SMS on your contact number?

Email : do you give consent to be contacted by your email address?

Family registered with us

Next of kin (Emergency contact - if different from above)

Other Information

If your child is under 1 year of age: were they premature?

Is your child home-schooled?

Has your child ever been suspended or excluded from school?

Has the child ever been the subject of a Child Protection Plan?

Has your child ever been a

Overseas visitor?

Armed Forces

Previous GP information

Housing

What type of house does the child live in

Language needs

Do you have any communication needs?

Carer details

Are you a carer?

Only add carer's details if they give their consent to have these details stored on your medical record

Do you have a carer?

Medical history

Have your child suffered from any of the following conditions?

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

Allergies

Current medication

Please attach if possible a copy of your repeat prescription request and include any other medication you may be taking which does not appear on your list. PLEASE NOTE AN APPOINTMENT WITH THE GP MAY BE NECESSARY FOR A MEDICATION REVIEW.

Upload

Max. size: 2.0 MB

Electronic prescribing

You do not need proof of ID to register with a GP, but it might help of you have one or more of the following: 1. Passport 2. HC2 certificate 3. Rough sleepers' identity badge 4. Hostel or accommodation registration or mail forwarding letter.

Photo Proof of ID

Max. size: 2.0 MB

Sharing your health record

Sharing Out: do you consent to your GP practice sharing your child’s health record with other organisations who care for them?

Sharing In: do you consent to your GP practice viewing your child’s health record from other organisations that care for them?

Your summary care record (SCR)

Do you consent to your child having an enhanced summary care record with additional information?

Online access of your health record

I wish to have online access for my child to: Please tick all that apply

I wish to access my child’s medical record & understand & agree with each statement: Please tick all that apply

Consent

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

To view our privacy policy, click here

I agree to be contacted via the details given above. I agree to the privacy policy