PRIORY AVENUE SURGERY
CHILD 14yrs & under
NEW PATIENT REGISTRATION FORM – CONFIDENTIAL
Please complete the following form IN BLOCK CAPITALS and return it to the surgery so that we can go ahead with your registration. The information provided will be entered into your computer record, and will help us to give you the best possible care, especially if you also respond to the invitation for a health check with the Practice Nurse.
Full Name: Mr/Miss/Other (please specify) ………………………………………………………………………………
Surname/s: …………………...……… Date of Birth (dd/mm/yyyy): ……………….……….…. Sex: Male/Female
Address: ……………………………………………………………………………………………………………...……………...
Tel. No.:Home……………………...………… Mobile …….……..……………………
Email address: ……………………………………………………………………
Ethnic Origin (please tick): Please note this information is used to establish disease trends
White British IndianMixed white/black Caribbean
White IrishPakistaniMixed white black African
Other whiteBangladeshiMixed white/Asian
Black CaribbeanChineseOther mixed
Black AfricanOther AsianOther ethnic group (Please specify)
Other blackPrefer not to answer
Religion: …………………………………………………….First spoken Language:…………………………….
Place of birth: Town……………………………………..… Country (if not UK) ……………………...……………………..
Next of Kin name: …………………………………………………………………….
(A person's next of kin is that person's closest living blood relative or somebody that you would want to contact in the case of an emergency)
Relationship to yourself: ………………………………………………………………………………………………
Address: ………………………………….....……………………………………………………………………………
Tel. No.: ………………….………...………………………………………………….
Do youhave a carer other than a parent? Yes/No If yes, who is it? (Please give name/address/relationship)………………………………………………..…………………………………………………………………………………….
Height: ………..……………. Weight: ……….…………..
Please list belowany regular medication that you take, whether you get it from your doctor or buy it over the counter?
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Important - Please make an appointment to see your doctor before any medication runs out.
Do you have any known allergies? Yes/No If yes, then please list below:
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Past medical history - please list any conditions (not minor) you have suffered from in the past, with dates if possible:
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Do you have any current medical problems? Yes/No If yes, then please explain below:
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Are you on a waiting list for a hospital appointment? Yes/No
If yes, please describe: ……………………………………………………………………………………………………………
Have your parents, brothers or sisters ever suffered from (please circle)?
Heart diseaseDiabetesStrokeCancer
AsthmaHigh blood pressureGlaucomaOther
If yes, then please give further details below, including family member affected:
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Is there anything else you wish to tell us about? ………………………………………………………………......
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Please supply dates of any immunisations your child has received: (Details can be found in their Red Book)
2 months old:Diphtheria,Tetanus,Pertussis (whooping cough), Polio, Hib
PneumococcalDate ……………….
3 months old:Diphtheria,Tetanus,Pertussis, Polio, Hib
Meningitis CDate ……………….
4 months old:Diphtheria,Tetanus,Pertussis,Polio, Hib
Meningitis CDate ……………….
PneumococcalDate ……………….
Between 12 and 13 months:Hib/MenC, Pneumococcal
Measles, Mumps and RubellaDate ……………….
3 years 4 months old:Diphtheria,Tetanus, Pertussis and Polio
Measles, Mumps and RubellaDate ……………….
Girls aged 12 to 13 years:HPVDate ……………….
13 to 18 years old :Tetanus, Diphtheria and PolioDate ……………….
Non-routine immunisation schedule
At BirthTuberculosis …………………………………………………………………
Hepatitis B …………………………………………………………………..
Any others not listed above (e.g. travel vaccinations)
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Your information will be uploaded to the National NHS Spine unless advised to the contrary.
PLEASE CONFIRM YOUR AGREEMENT TO THE ABOVE YES/NO
You confirm that the practice may contact you by telephone (land line or mobile) and that if required messages may be left on a named answer phone. You also agree that we can provide general practice information via email and SMS text messages.
Thank you for your time.
Please sign and date below
Signed ……………………………………………………...… Date …………………………………
Relationship to Patient ………………………………………