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


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.