Child new Patient Registration (0 to 15)

Patient’s Details

Please specify:

Family Name/Surname: *

Previous Family Names/Surnames:

Given Name(s)/First Name(s) *

NHS Number:

Gender Assigned at Birth: *

Male

Female

Do you currently identify as your birth gender?

Yes

No

Please describe your gender:

Town and Country of birth: *

Current Manchester Address: *

Postcode: *

How long will you be at this address?

Less than 3 months

More than 3 months

Are you in a stable housing situation?

Yes

No

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

Can we contact you by text?

Yes

No

Can we contact you by email?

Yes

No

If your child is from abroad

Date they came to live in the UK:

Please use this date format: DD/MM/YYYY.

Why did your child come to the UK?

Asylum Seeker/Refugee

To escape war/persecution (but did not apply for asylum)

Other

Previous Details

Name and address of previous GP:

Previous address while registered with that GP:

Please include postcode.

Details of First Parent/Guardian

Full Name: *

Relationship to child: *

Address:

Home Number:

Work Telephone:

Mobile Telephone:

Details of Second Parent/Guardian

Full Name:

Relationship to child:

Address:

Home Number:

Work Telephone:

Mobile Telephone:

Next of Kin / Emergency Contact

Who is next of kin/the emergency contact for the child?

First Parent/Guardian

Second Parent/Guardian

Both First and Second Parent/Guardian

Both First and Second Parent/Guardian and other

Other

First Name:

Relationship to child:

Phone Number:

Next of Kin address:

About Your Child

Other White please state:

Other Mixed please state:

Other Asian please state:

Other Black please state:

Any other please state:

Does your child have any problems speaking English?

I have no problems

I have some problems

I have a lot of problems

Does your child have any problems reading English?

I have no problems

I have a lot of problems

I have some problems

Main Spoken Language:

Main Reading Language:

Does your child need an interpreter when you visit the doctor?

Yes

No

Is your child a main carer (unpaid) for someone who has poor health or disability?

Yes

No

Please specify:

Health

Height of Child:

Weight of Child:

Does your child take regular medication?

Yes

No

Does your child have any long-term illness, health problem or disability?

Yes

No

Immunisations

Please give details of any immunisations your child has received and the date given:

School or Nursery

Name of School/Nursery:

Address of School/Nursery:

Brothers/Sisters/Siblings

Please give names and dates of birth for all siblings:

Summary Care Record

Your GP surgery needs permission to share important information from your GP record. This is called a summary care record (SCR). The SCR can only be shared with health and care staff across England who are providing you with direct care. It gives them access to vital information from your child’s GP record.

Your options are:

a basic summary care record that includes details of your child’s medicines, allergies and adverse reactions only
an enhanced summary care record that includes details of your child’s medicines, allergies, adverse reactions and any significant illnesses and health problems, operations and vaccinations
opting out of a summary care record meaning you do not want any information shared with other healthcare professionals involved in your child’s care

What is your choice for the child’s summary care record?

Basic summary care record

Enhanced summary care record

Opt out of a summary care record

Your Details

Your Full Name: *

Relationship to the child:

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