Under 16s New Patient Registration Completing this form is the first step to registering with the practice. You will need to provide some identification on your first visit to the practice. Patient DetailsHealth InformationFurther Information0% Complete1 of 3 Patient's Details Title * Miss Master Surname * Date of Birth (DD/MM/YYYY) * First names * NHS Number Previous surnames Gender * Male Female Town and country of birth * Home address * Postcode * Name of current school About You (Parent/Guardian) Name of adult registering the child: * Relationship to child: * Parent/Guardian's Email Address: * Parent/Guardian Telephone Number: * Mobile number for text message reminders. Parent/Guardian's Full Address inc postcode: * How would you like us to contact you about your child? * Letter Email Text Phone Who has legal parental responsibility? * Mother Father Both Other Mother's full name: * Mother's NHS number: Is mother registered at this surgery? * Yes No Does mother reside with the child? * Yes No Father's full name: * Father's NHS number: Is father registered at this surgery? * Yes No Does father reside with the child? * Yes No Full Name: * Relationship to child: * Are you registered at this surgery? * Yes No Is address the same as the child's? * Yes No Address including Postcode: * Carers Information Is your child looking after someone? Yes No eg. someone who is ill, frail, disabled, has mental health/emotional support issues or substance misuse Relationship to child * Does your child have a carer? Yes No eg. family member, friend or neighbour Carer's Name * Carer's Phone Number * Preferably a mobile number Carer's Address * Does your child need help with mobility/hearing/speaking? * Yes No Please give details: * eg. Wheelchair, hearing aid, braille, lip reading, sign language etc. Is your child housebound? Yes No Ethnic Origin Please select the ethnic group which you consider your child belongs to * White British White Irish Other White Black Caribbean Black African Other Black Black Caribbean and White Other Mixed Indian Pakistani Bangladeshi Other Asian I do not wish to state Other ethnic group (please state) Is English your child's main spoken language? * Yes No What is your child's main spoken language? * Does your child need an interpreter? Yes No What is your child's religion? Church of England Catholic Buddhist Hindu Muslim Sikh Jewish Jehovah's Witness No Religion Other Religion: Is your child currently: Homeless A refugee A asylum seeker Medical Records Please help us trace your previous medical records by providing as much of the following information as possible. Child's previous address in UK Name of previous doctor while at that address Address of previous doctor If you are from abroad Child's first UK address where registered with a GP If previous resident in UK, date of leaving: Date child first came to live in UK: Please state all countries your child has lived in, or visited for longer than 6 months Please include dates/years.