Child New Patient Registration Philip Lane Child New Patient Registration (Ages under 18) – Philip Lane Patients Registration Form (Child) - Philip Lane Please upload birth certificate/proof of guardianship. Please also provide copies of immunisations (if aged under 5) *(Required) Drop files here or Select files Max. file size: 50 MB. Background Details Your Child's DetailsNHS Number(Required) Title(Required)Please SelectMrMsMrsMissMxFirst Name(Required) First Surname(Required) Last Gender(Required) Date of Birth(Required) Day Month Year Address(Required) Street Address Address Line 2 City Postcode Contact Number(Required)Parent or Guardian DetailsYour Name(Required) Relationship to Child(Required) Address(Required) Street Address Address Line 2 City Postcode Home TelephoneWork TelephoneMobile Telephone(Required)Do you consent to be contacted by SMS?(Required) Yes No Email(Required) Do you consent to be contacted by email?(Required) Yes No Family Registered with UsOther Details Previous GPName of Previous GP(Required) Address(Required) Street Address Address Line 2 City Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Childs Other DetailsTown & Country of Birth(Required) Ethnicity(Required) White (UK) White (Irish) White (Other) Black Caribbean Black African Black Other Bangladeshi Indian Pakistani Chinese Religion C of E Catholic Other Christian Buddhist Hindu Muslim Sikh Jewish Jehovah's Witness No Religion Is your child an Overseas Visitor?(Required) Yes European Health Insurance Card Held (please bring details with you) No Do you have any family members in the Armed Forces?(Required) Yes No Please give details of family members who are in the Armed Forces:(Required)Communication Needs LanguageWhat is your childs main spoken language?(Required) Do you need an interpreter?(Required) Yes No CommunicationDoes your child have any communication needs?(Required) Yes No Please specify(Required) Hearing aid Lip reading Large print Braille British Sign Language Makaton Sign Language Guide dog Learning DisabilityDoes your child have a Learning Disability?(Required) Yes No (If yes please request a Learning Disability Screening Tool form)Medical HistoryHas your child suffered from any of the following conditions? Asthma COPD Epilepsy Heart Disease Heart Failure High Blood Pressure Diabetes Kidney Disease Stroke Depression Underactive Thyroid Cancer For Cancer, please specify which type(Required) Any other conditions, operations or hospital admission details: If your child is currently under the care of a Hospital or Consultant outside our area, please tell us here: Family HistoryPlease record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent.Medical problem Asthma COPD Epilepsy Heart Disease Stroke Blood Pressure Diabetes Kidney Disease Liver Disease Depression Thyroid Cancer Other For Other please specify below Relative Father Mother Brother Sister Grandmother Grandfather Extended Family member (Aunt/Uncle/Cousin) AllergiesPlease record any allergies or sensitivities below Current MedicationPlease check and include as much information about your child's current medication below.If they have a previous repeat medication list please give this to us and they may need a medication review appointment:Further Details Electronic PrescribingIf you would like your child's prescriptions to be sent electronically, please provide details of the pharmacy you would like to use: Parent or Guardian Signature Please provide your full nameSharing Your Childs Health RecordDo you consent to your GP Practice sharing your child's health record with other organisations who care for you?(Required) Yes (recommended) No - Never Do you consent to your GP Practice viewing your child's health record from other organisations that care for you?(Required) Yes - (recommended) No Your Childs Summary Care Record (SCR)Do you consent to your child having an Enhanced Summary Care Record with Additional Information?(Required) Yes - (recommended) No Parent or Guardian Signature(Required) Please provide your full nameDate(Required) Day Month Year CommentsThis field is for validation purposes and should be left unchanged.