Victoria Road Surgery

New Patient Registration – Child

Everyone is welcome in general practice. You do not need to provide proof of ID, address, immigration status or an NHS number in order to receive care or see a GP.

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.

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

Your child details

Child’s Surname

Child’s First Name(s)


Previous Surnames

Date of birth

Address and Postcode

Telephone Number

Parent or guardian details

Mother's name

Telephone number

Address details (if different from child’s)


Father's name

Telephone number

Address details (if different from child’s)


Someone else (please state name and relationship to child)

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?

If No, which school do they attend?

Has your child ever been suspended or excluded from school?

Name of health visitor/school nurse (if known)

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

If yes, when?

Has your child ever been a

Country of birth




Overseas visitor?

Armed Forces

Previous GP information

GP full name

GP practice address


What type of house does the child live in

House or flat (If flat which floor?)

Are there any housing problems? e.g. overcrowding, damp

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

Language needs

What is your main spoken language?

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?

If Yes, please enter the name of the carer

Carer contact number

Relationship with the carer

Medical history

Have your child suffered from any of the following conditions?

Any other conditions, operations or hospital admission details

If your child currently under the care of a hospital or consultant outside our area, please tell us here

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

If other condition, please state here


Please record any allergies or sensitivities below

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.


Max. size: 2.0 MB

Current medications

Electronic prescribing

If you would like your prescriptions to be sent electronically, please provide details of the pharmacy you would like to use

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.

If you're homeless, you can give a temporary address, such as a friend's address, a day centre or the GP surgery address

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


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