Patient Registration Form – CHILD (Appendix A) /
Child Under 16 Registration Form (persons over 16 to complete own full application form) / PRIMARY
A1. Parent / Legal Guardian Information(Parent/Guardian Must Also Be Registered with the practice)
Forename(s): / Relationship to child:
Surname: / EMIS ID (Practice Use):
A2. Child Information
Forename(s): / JSY Social Security No:
Surname: / School:
Date of Birth: / Male/Female:
A3. Medical History
Does the child suffer from any Allergies?: Yes No
If Yes please provide details:
Does the child currently take any medication?: Yes No
If Yes please provide details:
Does the child suffer from any significant ongoing medical problems?: Yes No
If Yes please provide details:
Has the child had any serious illness or operations in the past?: Yes No
If Yes please provide details:
A4. Immunisation History (IMPORTANT: Please provide copy of Red Book or Immunisation History/Record)
2 Months
3 Months
4 Months
12 Months / 13 Months
3 Years
13 Years
HPV
Please provide to the practice any information regarding any other vaccinations given to this child.
A5. Previous/Existing GP Information Tick Box if GP is the same as Parent / Legal Guardian
GP Name: / Telephone Number:
Address:
Reason For Leaving:
Medical Records: / Do you consent to us requesting the child’s medical records from the previous GP Yes No
(If Yes See SectionA6.)
A6.Patient Declarationand Personal Data Statement(Signed By Parent/Legal Guardian)
Applicant Declaration, Confidentiality Agreement and Personal Data Statement as per Parent/Guardian Application form. As per my consent in Section A5 of this application form, I hereby give my express permission to the Practice to request information and records from the above child’s previous GP and I agree to meet all charges relating thereto for providing such information.
Signed: / Print Name: / Dated:
For LMP Use Only
Medical Records Transfer Consent Form Completed
For LMP Use Only / Received By: / On System By: / EMIS Number:
Past medical records requested* / Requested By:
Patient registration book updated / Registration reviewed by Doctor
Other GP Informed of Registration: / Informed By/Date:
EMIS registration(JY number must be added to: Social Security Number and Health Insurance Number)
- Send Medical Record Transfer Consent form (signed) to existing GP as authorisation to release medical records to the Practic.e
- Individual Form Appendix A to be completed for each child under age of 16
- Separate registration forms to be used for visitors or secondary users of the practice.
PRF-PRIMARYAA V.001 | Page 2 of 2