Riverside Surgery, George Street, High Wycombe HP11 2RZ
Please bring the child’s Red Book with you so we can take a copy of their immunisation record.
CONFIDENTIAL MEDICAL REGISTRATION FORM (Children Under 16)	
	
Child’s Personal Details:	
	
Please complete all pages in FULL using BLOCK capitals
Child’s Surname:		
		
Child’s First Names (in full):		
		
Previous Surnames:		
		
Title:	 Master        Miss     Ms		 Male         Female	
		
Date of Birth (day/month/year):							NHS Number:
(if known)											
													
Town & Country of Birth:		
		
Address:	

Post Code:   	
		
Telephone Number:		Mobile Number1:		
	1  Note, we use the mobile number for text messages.
Text messages will automatically cease when the Child is 11 years old.	
				
Email Address2:		
		
2  Please specify whose above email address this is, e.g. parent, guardian etc.		
		
Name of Parent(s) / Carers	Has Legal / Parental Responsibility?	Next of Kin?	
1.	  	           Yes                          No	      Yes             No	
2.	  	           Yes                          No	      Yes             No	
If not the above, name of person with legal responsibility:		
Contact details of person with legal responsibility		

Does the child have any special communication / mobility needs?  	 Yes        No
If yes:  	 Wheelchair	 Walking Aid    	 Hearing Aid    	 Large Print    
		 Lip Reading	 Braille   		 British Sign Language   
		 Makaton Sign Language   		 Other: ….…………………………………..	

Is the child currently:				 A Refugee     An Asylum Seeker
Is the child a child in care?				 Yes        No
Is the child a “Looked After Child”?		 Yes        No
If yes to either of the above questions, in what capacity?     Temporary	 Permanent
Is the child home educated?			 Yes        No	   
Name of Social Worker: 	…………………………………………………………………………………………
Social Worker’s Phone No: 	………………..……………………………………………………………………….
Name of child’s nursery/school ……………..……………………………………………………………………….	

Has the child or family either currently or in the past been known to Children’s Services?

	 Yes        No

Name of Social Worker: 	…………………………………………………………………………………………
Social Worker’s Phone No: 	………………..……………………………………………………………………….

Required Information:	
	
Is your child looking after someone at home?				 Yes       No
If so, who3?		
3   Please tell us if the child is looking after someone who is ill, frail, disabled, has mental health/emotional support needs or substance misuse problems
What is the adult’s relationship to the child?		

Do you think the child would like additional support as a young carer?	 Yes       No
Is the child known to services such as Young Carers?			 Yes       No
	
Is the child being privately fostered (see definition below)?			 Yes       No
If yes, please provide carer’s name:		
Carer’s relationship to child:		
Contact details of carer:		

Are Children’s services aware?						 Yes       No	
Private fostering is an arrangement whereby a child under the age of 16 (or 18 if the child has a disability) (S.66 Children Act 1989)  is placed for 28 days or more in the care of someone who is not the child’s parent(s) or a ‘connected person’. Private foster carers can be from the extended family, e.g. a cousin or a great aunt, but cannot be a relative as defined under the Children Act 1989, section 105:‘A relative under the Children Act 1989 is defined as a ‘grandparent, brother, sister, uncle or aunt (whether full blood or half blood or by marriage or civil partnership) or step-parent’.
Please help us trace the child’s previous medical records by providing the following information:	
	
Your previous address in the UK:	

Post Code:  	
		
Name of previous Doctor while at that address:		
		
Surgery Name and Address of previous Doctor:	

Post Code:  	
		
If you are from abroad:	
	
Your first UK address where Registered with a GP:	

Post Code:  	
		
If previously resident in UK date of leaving:		Date you first
came to the UK:		

If registering a child under 5:	
	
 I wish the child above to be registered with Organisation Name  for Child Health Surveillance
If you need your doctor to dispense medicines and appliances*:	
	
For Dispensing Practices only:
 I live more than 1 mile in a straight line from the nearest chemist
Patient Declaration for all patients who are not ordinarily resident in the UK:	
	
Please see appendix 1 for patient declaration (last page of form)

Child’s Personal Medical History:	
	
If under 5 years old, type of Birth: 
(eg normal, forceps, caesarean)		
		
Has your child ever suffered from any important medical illness, operation or admission to hospital? If so please enter details below (if extra space is required please use box at end of form):

Condition	Year Diagnosed	Ongoing	

		Yes/No	

		Yes/No	

		Yes/No	

Family Medical History:	
	
Have any close relatives (father, mother, sister, brother only) ever suffered from: (please indicate who in the boxes)

	Heart Disease	Stroke	Diabetes	High Blood Pressure	Asthma	Glaucoma	Cancer	Mental Health Problems	Renal/ Kidney	Learning Difficulties	
At the time of diagnosis they were:	
Over
60 yrs old											
Under 
60 yrs old											

Child’s Immunisations:	
	
Please provide details of your child’s immunisations with dates if possible (under 5’s).  If possible please give your Red Book to Reception to photocopy:

Immunsation	Date	Immunisation	Date	
Tetanus		Booster: Tetanus		
Whooping Cough		Booster: Diphtheria		
Polio		Booster: Polio		
HiB		Booster: MMR		
Measles				
MMR				
BCG (TB)				
Meningitis				

Child’s List of Current Medication:	
	
Name of Medication 	Dosage	

		

		

Child’s Allergies:	
	
Please list any allergies the child has to any drugs/medications or if known egg allergy or peanut allergy:
Name of Medication 	What was the problem or upset?	

		

Child’s Ethnicity:	
	
 British or mixed British	 Irish       	 African      	 Caribbean       Indian       Pakistani  
 Bangladeshi  	           		 Chinese 	 Other (please state): 
 Decline to state

Child’s Religion:	
	
Please state religion of child:		

Please advise if you feel your child’s religion will affect any treatment received:         Yes       No

Child’s Language:	
	
Please state child’s main spoken language:		

Does the child need an interpreter?	        	     Yes       No

Data Sharing Consent Choices:	
	
To maintain continuity of clinical care, we upload certain medical information so that it is available to other healthcare organisations (eg Emergency Departments).  Please read the accompanying leaflet which details what part of your record is extracted and how it is used to help other NHS organisations.  

If you wish to OPT OUT please complete the form found with this leaflet.

Where you have provided information on how to contact you, can you confirm you are happy for [insert name of practice] to contact you by the following:

By email 		  Yes       No       This will be to send you letters, the practice newsletter and the like
By text		  Yes       No       This will be to send you reminders of appointments via text

Signatures:	
	
I confirm that the information that has been provided is true to the best of my knowledge.

Signed:		Date:		

Signature on behalf of patient     Signature of patient       

Name of Person		Relationship to Child:		

Box for extra details:	

Updated 26/09/17											Appendix 1

PATIENT DECLARATION for all patients who are not ordinarily resident in the UK	
	
Patient’s Details	Please complete in BLOCK CAPITALS and tick  as appropriate	
 		
 Mr      Mrs      Miss      Ms
		Surname:		
			
Date of
Birth								First Names:		
										
NHS
No.												Previous
Surname/s:		
														
 Male      Female
		Town and
Country of Birth:		
			
Home Address:

	

Postcode:   	
Telephone No:   	

Scan and send this page of form to: NHSDigital-EHIC@nhs.net