Patient registration forms for under 18’s

Patient Child (Under 18years old) Registration Form (GSM1 + Health Q’s)

Patient Child (Under 18years old) Registration Form (GSM1 + Health Q’s)

If you are new to the area, under 18 years old and wish to register with the Practice please complete the form below – each person registering will need to complete a form.

We also ask if you can send in a copy of the child’s birth certificate or passport and the first page of the red book.

Title: *
Address *
Consent to contact you via your email address
Consent to SMS text messages for appointments reminders etc

Please help us trace your previous medical records by providing the following information:

Your previous address in the UK *
Your previous address in the UK
Address of previous doctor *
Address of previous doctor

If you are from abroad:

Your first address where registered with a GP *
Your first address where registered with a GP
What is your current immigration status?

Communication Needs

Do you speak English?
Do you read English?
Do you have speical communication needs e.g Speech, Hearing, Visual that may require the services of one or more of the following?

Armed Forces

Have you served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas?
What is your current immigration status?


Do you look after someone, or does someone look after you with your daily needs

Family Details

Who has parental responsibility?

Emergency Contact

Full Name
Full Name
Are they your next of kin?
Do you give us permission to discuss your medical records with them?

Additional Contact

Are they your next of kin?
Do you give permission to discuss your medical records with them?

Other Information

Is your child home-schooled?

Housing – Please list all the people (children and adults) that share the house with the child and their relationship to the child

Family Medical History

Has any of your immediate family (Parents, Brothers, Sisters, Grandparents, Aunties, Uncles) suffered from any of the following?

Repeat Medication


Do you have any allergies?

Immunisation History – If you have your child’s red book please take a copy of their immunisations and pop them into reception, if not please complete the information below

Please include dates.

Summary Care Record

This record will contain summary information about any medicines you are taking, allergies you suffer from and any bad reactions to medicines you have had to ensure those caring for you have enough information to treat you safely.

Your Summary Care Record will be available to authorised healthcare staff providing you with care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill away from home, healthcare staff treating you will have immediate access to important information about your health.

Do you consent to having a Summary Care Record?

Your Medical Information – Sharing Your Data

Under the General Data Protection Regulations (GDPR), we have a responsibility to keep your medical records confidential. We need your consent to share this with other authorised health professionals involved in your care or in planning your care. You can find more information on the website at

Please see the privacy notice on our website for more information on how your data is held and used by the practice.

The NHS wants to make sure you and your family has the best care now and in the future. Your health and adult social care information supports your individual care. It also helps us to research, plan and improve health and care services in England.

There are very strict rules on how this data can and cannot be used, and you have clear data rights. We are committed to keeping patient information safe and will always be clear on how it is used.

You can choose whether or not your confidential patient information is used for research and planning.

If you do not wish your information to be used in this way please opt-out by visiting NHS: Your Data Matters or by calling 0300 303 5678. The practice is unable to record this for you.

NHS Organ Donor registration

For more information on organ donation please visit:

NHS Blood Donor registration

If you would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood, please visit their website on: or call direct on 03001232323

What happens to my information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some are kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred to by your GP in order to provide continued healthcare and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.