UNDER 18s NEW PATIENT REGISTRATION FORM including GMS1 V2

Fields marked "REQUIRED" are compulsory.. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 09/12/2020

Details of child registering






Home address of child






About the applicant













Current Contact Details for the child






Person with parental responsibility

NB. Parent or guardian must also be registered with the practice












Home address if different to child's







Current Contact Details of person with parental responsibility







Legal orders


Please help us trace the previous medical records of the child by providing the following




School


Caring Responsibilities of the child

Caring for a child

















Caring Responsablity of the child

Caring for an adult








Do you (the child) have a carer




Any other adults who reside in your home











Child's Medical History


Child's Current Medications




Chld's Immunisation History

Please give the date of your immunisations



















Childhood Illness


Child's Lifestyle History


















Online Services Registration



Summary Care Record Sharing


Parent / Guardian / Patients Declaration

By signing below you are declaring that the information contained within this patient registration form is accurate to the best of your knowledge. Any suspected fraudulent information will be reported to the relevant authorities.






NON-UK European Health Insurance Card (EHIC), Provisional Replacement Cerificate (PRC) details and S1 forms

Complete this section if the applicant lives in another EEA country, or has moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK. If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC) / S1, you may be billed for he cost of any treatment received outside the GP practice, including at hospital).















How will your EHIC / PRC / S1 data be used?

By suing your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process. Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.