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Child Registration

New Patient Registration Form (Child) [PDF]

Online Registration

Quote / Testimonial:

If your child is under the age of 6 years old you must provide vaccination history.

The registration will not be processed without this information.

Please complete as many questions as you can about your child. The information will help the practice to provide better medical care for your family.

Patient Information

Childs Name

First Last

Any Previous Surname(s) Optional

Gender

Male

Female

Place of birth

Date of birth

Day

Month

Year

Ethnicity

Main Language Spoken

Current Address

Street Address Address Line 2 City Postcode

Medical History

Does your child have any medical condition?

Yes

No

Please give details

Does your child have any additional needs or disabilities?

Yes

No

Please give details

Please list any medication that your child is currently taking

Please list any medicines, foods, plants or animals to which you think your child is allergic

Smoking Status

Yes Optional

No Optional

(for 15 years only)

Do you wish to discuss stopping smoking?

Yes

No

Parental/Guardian Details

Parent/Guardian Name

First Last

Relationship

Contact Number

Email

Enter Email Confirm Email

Who else lives in your household with your child? Optional

Do you have parental responsibility for the child?

Yes

No

Is the child you are registering “Looked After” by the local authority or subject of a Child Protection Plan?

Yes

No

For more support check out: www.salford.gov.uk/health-and-social-care/caring-for-someone/young-carers/

Do you know the name of your child’s Health Visitor?

Yes

No

Please give details

Is there anything else you think the practice should be aware of?

Yes

No

Please give details

Next of Kin

Name

First Last

Contact Number

Relationship

Summary Care Record Sharing

Do you object to your child’s summary care record being available when you access NHS care outside of your GP Practice (for example NHS Out of Hours Services or Accident & Emergency)?

Yes

No

Thank you for your cooperation. If you have any other specific concerns about your child’s medical care that you would like us to be aware of, please do book an appointment with the practice.

Name of person completing form

First Last

Relationship to child

Our Locations

0161 983 0190

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Clarendon Medical Practice

1st Floor,
Pendleton Gateway,
1 The Broadwalk,
Salford,
M6 5FX

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The Angel Medical Practice

St Phillips Place,
Chapel Street,
Salford,
M3 6FA

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