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:

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

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:

Your Details

Your Full Name: *

Relationship to the child:

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