Adcroft Surgery
CONFIDENTIAL MEDICAL REGISTRATION FORM - CHILDREN (under 16)
ID you have provided: Birth certificate
Passport
Please complete all pages in FULL using BLOCK capitals
Surname
First Names (in full)
Previous Surnames
Title:  Mr  Mrs  Miss  Ms
Date of Birth (day/month/year)
 Male
 Female
NHS Number
Town & country of Birth
Address
Post Code:
Telephone number:
Email address:
Mobile number:
Please help us trace your previous medical records by providing the following information:
Your previous address in UK
Post Code:
Name of previous Doctor
while at that address
Address of previous Doctor
Post Code:
If you are from abroad:
Your first UK address where
Registered with a GP
Post Code:
If previously resident in UK
date of leaving
Date you first
came to UK
If registering a child under 5:

I wish the child above to be registered with Adcroft Surgery for Child Health Survelliance (eg
vaccinations)
Personal Medical History…..
Type of Birth:
(eg normal, forceps, Caesarean
If under 5)
Birth Weight:
Feeding:
(If under 5)
(Breast or bottlefed
If under 5)
Has your child ever suffered from any important medical illness, operation or admission to hospital? If so
please enter details below:
Condition
Year diagnosed
Ongoing
Yes/No
Yes/No
Yes/No
Family History…..
Have any close relatives (father, mother, sister, brother only) ever suffered from: (please indicate who in the
boxes)
Heart attack
Stroke
Diabetes
High blood
pressure
Asthma
Glaucoma
Cancer
Immunisations ……
Please provide details of your childs immunisations with dates if possible (under 5’s). If possible pelase
give your Red Book to Reception to photocopy:
Immunsation
Tetanus
Whooping Cough
Polio
HiB
Measles
MMR
BCG (TB)
Meningitis
Date
Immunisation
Booster: Tetanus
Booster: Diphtheria
Booster: Polio
Booster: MMR
List of current medication ……
Name of medication
Dosage
Date
Allergies ……
Please list any allergies you have to any drugs/medication:
Name of medication
What was the problem or upset?
Ethnicity ……
vej
 British or mixed British
 Bangladeshi
 Decline to state
 Irish
 African
 Caribbean
 Chinese  Other (please state):
 Indian
Main Language spoken………………………………………………….
If this is not English is English also spoken? Yes / No
Next of kin ……
Name:
vej
Tel. contact
number:
Relationship:
Parental responsibility
Mothers full Name
Fathers Full name
Are both parents registered at Adcroft Surgery?
If not please state which surgery………………………………………………………………
If someone other than a parent has legal responsibility for this child please give details
 Pakistani
Data sharing consent choices ……
vejof clinical care, we upload certain medical information so that it is available to
To maintain continuity
other healthcare organisations (eg Emergency Departments).
If you wish to OPT OUT on behalf of your child please ask for a leaflet & form at reception.
Where you have provided information on how to contact you, can you confirm you are happy for [insert
name of practice] to contact you by the following:
 Yes
By text
 No
This will be to send you reminders of
appointments via text
Signature ……
vej
I confirm that the information that has been provided is true to the best of my knowledge.
Signed:
Signature on behalf of patient 
Date:
………………………………..(relationship)
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
For reception use only – please ensure the following information has been provided
 ID checked: Birth certificate / passport (please circle or use stamp)
 Does the parent wish to nominate a local pharmacy? ………………………(please
state which one)
 NHS number has been provided
 Place of Birth
 Full first & middle names
 Old and new postcode
 Parent names (parental responsibility)
 Ethnicity
 signature
Registration form checked by ……………………………………………..(receptionist)