RISING BROOK
& CROSS STREET SURGERY
NEW BABY / CHILD (under 16) APPLICATION
All information is confidential
Full Name of child:……………………………………………………………Date of Birth:…………………………
Full Names of Parents:..……………………………………………………………......
………………………………………………………………………………………………………………………………...
Address: …………………………………………………………………………………………………………………….
………………………………………………………………………………Postcode: …………………………………...
Telephone: ………………………………………………… Mobile: ……………………………………......
Can messages be left on this number Yes / No Can messages be left on this number Yes / No
Would you like access to:
Book& Cancel Appointments onlineOrder Repeat Medication online
PARENTAL RESPONSIBILITYIf the child’s natural parents are not married at the time of birth, fathers do not automatically have parental responsibility.If your child was born on or after 1 December 2003 both parents have parental responsibility ONLY where the birth was registered together and the birth certificate signed by both parents. If your child was born on or before 30 November 2003, the natural father does not have parental responsibility but can acquire it through the Courts etc. For further information please go to
If the child’s natural parents are married at the time of birth, both automatically have parental responsibility.
Please circle who has Parental Responsibility;
MOTHER ONLYMOTHER AND FATHER
OTHER (please state) …………………………..……………………………………………………………….
(Evidence will be required, i.e. court or residence order, adoption certificate etc)
Information regarding your child can only be shared with anyone who has parental responsibility for the child whether or not they are living with the child.
Please state who can collect prescriptions;
- Name ……………………………………………….…… 2. Name ………………………………………………….
Permanent UK resident?YESNO
FIRST LANGUAGE ………………………………………………………………………………………………………..
Ethnic Origin: (tick as appropriate)
Bangladeshi / Indian / PakistaniOther Asian / British / Chinese
Irish / Other White / Black African
Black Caribbean / Mixed White and Black African / Mixed White and Black Caribbean
Other Black / Mixed other Background / Mixed White and Asian
Any Other
The UK is an increasingly ethnic diverse society. Information on ethnicity is important because of the need to take into account culture, religion and language in providing appropriate individual care, changing legislation, the importance of providing information on ethnicity for shared care including secondary care and the need to demonstrate non-discrimination and equal outcomes.
RISING BROOK
& CROSS STREET SURGERY
Medical History – please list any important operations, physical or mental health problems that you have had in the past;
………………………………………………………………. / ………………………………………………………………………………………………………………………………. / ………………………………………………………………
Current Medication – are you on any medication, either prescribed by your previous GP or that you purchase from the chemist? If so please list;
………………………………………………………… / …………………………………………………………………………………………………………………… / …………………………………………………………
Are you allergic to any drugs? If so please list ……………………………………………………………………….
Do you suffer with any of the following?
AsthmaYESNO
DiabetesYESNO
Heart ConditionYESNO
Renal ConditionYESNO
Do you smoke?N/AYESNO
If yes:
Number of cigarettes per day? ………………………….Number ofCigars per day? …………………………..
Ounces of Tobacco per day? …………………………….
ExerciseDo you take, as a minimum, three brisk 20 minute walks or the equivalent in a week?
YESNO
DietDo you eat some of meat, milk, vegetables and fruit each day?
YESNO
Are you on a special diet? (Please provide details) ......
What is your weight? ……………………………………………………………………………………………………..
What is your height? ……………………………………………………………………………………………………..
What School or College do you currently attend? …………………………………………………………………
………………………………………………………………………………………………………………………………...
THANK YOU FOR COMPLETING THIS APPLICATION
Date of Completion…………………………….