New Patient
Registration Form
Under 18
Welcome to Worthing Medical Group. We are pleased that you have chosen us as your medical practice.
This form is very important – it helps us collect the information we need to register your new details with
the NHS and organise any further tests or investigations that might be needed. All your information is kept
strictly confidential within the NHS and not shared or used without your consent.
PLEASE COMPLETE ALL DETAILS AS FULLY AS POSSIBLE: Areas marked * are mandatory
BASIC DETAILS
Surname *
Forenames *
Preferred name
(if different to above)
Your child’s date of
birth *
Your child’s current
home address
including postcode *
Male or Female *
Place of birth *
Your child’s home
phone number
Who has parental
responsibility for your
child?
Parental mobile
phone number
We send automatic text message reminders the day before your appointments with us and you can cancel your
appointments by text as well. To OPT OUT of this free service tick this box
Patient Access is an internet service through our website that lets you book and cancel appointments on-line for your child
and also order their repeat medicines for collection /delivery at any local pharmacy. If you would like to register your child
for Patient Access, please speak to a member of the Reception team.
INFORMATION SO WE CAN TRACE THEIR MEDICAL RECORDS
NHS number *
Your child’s previous
address including
postcode *
Previous GP *
Name
Address
Has your child been
registered here before?
If your child has moved
from abroad, date of
arrival in the UK
No
Yes
If so, when?
Next of kin
Name
Address
Phone number
Relationship to child
Special Circumstances
Please tick if any of
these apply to your child
Live in a nursing home
Asylum seeker
Live in a residential home
Live in a children’s home
ABOUT YOUR CHILD’S PAST MEDICAL HISTORY
Do they currently suffer
from any additional
needs / medical
problems / conditions /
illnesses / diseases? *
Date
Please give brief details
and approximate dates
Have they had any
significant additional
needs / medical
problems / diseases /
illnesses / operations in
the past? *
Please give brief details
and approximate dates
Immunisations *
Please list any recent
immunisations e.g. flu,
pneumococcal etc.
Please list all your
child’s current
medications *
Date
Date Given
2 months – 5 in 1 & Pneumococcal
3 months – 5 in 1 & Meningitis C
4 months – 5 in 1 & Pneumococcal & Meningitis C
12 months – HIB/Meningitis C
13 months – MMR & Pneumococcal
Under 5 – Pre-school booster & MMR
Other (including travel or special immunisations e.g. hepatitis B, TB etc.)
Dose / Strength
e.g. 20mg tabs
Times per day
Ensure you include
inhalers, dressings and
appliances. (or you can
attach a copy of your
previous GP’s repeat
medicines list if you
prefer – tick here
)
If your child is on repeat medicines you must make an appointment for them with your new GP. Please ask the
receptionist to organise an appointment for you at a convenient time.
We will send their prescriptions to your preferred local
pharmacy where you can collect their medicines at your
convenience (or have them delivered). Which pharmacy
would you like to use?
Does your child have
any allergies? *
Please also tell us the
nature of the reaction
Family History
Detail of who is affected
Heart attack/ angina (onset before age 60)
Heart attack/ angina (onset after age 60)
Stroke
Diabetes
Cancer: (type)
Any other inherited condition:
Please tick any of the
following that apply to
first degree relatives
(parents, children,
brothers & sisters)
PHYSICAL DETAILS
The surgery has a free height and weight machine operated by a token, available from reception.
Weight *
Height *
We prefer kg but are
happy with st and lb
We prefer cm but are
happy with ft and in
ETHNICITY AND LANGUAGE
White
Ethnic Origin *
Knowing their ethnic
origin is important for
some of our tests and
may affect which
medicines work best for
them.
British
Irish
Other
Asian / Asian British
Indian
Pakistani
Bangladeshi
Black / Black British
Caribbean
African
Other
Other/Other British
Chinese
Other
Other
First Language
EDUCATION AND SUPPORT
Who else lives in your
household with your
child?
Name
Relationship to the child
Which school or nursery
does your child
currently attend?
Please detail the nursery/school and date attendance began:
Which school or nursery
did your child
previously attend?
Please detail the nursery/school and dates of attendance:
Is your child ‘Looked
After’ by the local
Yes
No
authority?
If yes – please give details of care order, parental responsibility and carers details etc.
Has anyone in your
family ever had a social
worker?
Yes
No
If yes – please give further details:
Is your child a carer for
anyone?
Yes
No
If yes – for whom?
DECLARATION
I declare that my child* is entitled to NHS services because I have been or intend to be ordinarily resident in the UK for a period
of 6 months or longer. I am registering them with Worthing Medical Group and authorise them to obtain my past medical
records from my previous UK GP.
Signature:
Date:
(Write “signed electronically” if you are submitting by -mail)
Name (print):
Relationship:
For Surgery Use Only
Form accepted & checked by:
Patient informed of Named GP:
Smoking cessation advice provided by:
or
N/A
Registered on EMIS as temporary pt by:
Details of any appointments made:
Patient registered as active on EMIS by:
Data template completed by: