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.
Your child details
Child’s Surname
Child’s First Name(s)
Gender
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)
Name
Telephone
Address
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
Ethnicity
Religion
Housing
Overseas visitor?
Armed Forces
Previous GP information
GP full name
GP practice address
Housing
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
Allergies
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.
Upload
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
Consent
I confirm that the information I have provided is true to the best of my knowledge
To view our privacy policy, click here