Application to Register - CHILDREN (UNDER 18s)

Application to Register - CHILDREN (UNDER 18s)

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. Your details will be kept at the surgery and must be signed by you during your first appointment. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register

  • Personal Details

    Date of Birth
    For example, 15 3 1984
    GENDER/GENDER IDENTIITY

  • IF YOU HAVE HAD A GP IN THE UK BEFORE

    Please make sure you fill in all details below as if there is any missing information you will not be registered.

  • IF YOU ARE FROM ABROAD

    This section is to be fill out if you had not had a GP in the UK before. Please make sure you fill in all details below as if there is any missing information you will not be registered.

    DATE YOU FIRST CAME TO LIVE IN THE UK (optional)
    For example, 15 3 1984

  • PATIENT DECLARATION

    I declare that the information I have given on this form is correct and complete. I understand that, if it is not, appropriate action may be taken. To enable NHS National Services England to confirm my eligibility to lawfully register with a GP and for the purposes of prevention, detection, and investigation of crime, relevant information from this form will be disclosed to the NHS Business Services Authority, NHS National Services England, the Home Office, Identity and Passport Service, HM Revenue and Customs, the General Register Office and Local Authorities.

    DATE (optional)
    For example, 15 3 1984

  • NEW PATIENT QUESTIONNAIRE

    We need you to fill out the following information

    RELIGION
    DO YOU OR THE CHILD CONSIDER THEM TO HAVE A DISABILITY
    ETHNICITY
    COMMUNICATION REQUIREMENTS
    PARENT/CARER DETAILS 1 - date of birth
    For example, 15 3 1984
    PARENT/CARER DETAILS 2 - DATE OF BIRTH (optional)
    For example, 15 3 1984
    IS THE CHILD SUBJECT TO ANY LEGAL ORDERS
    BCG IMMUNISATION - DATE GIVEN (optional)
    For example, 15 3 1984

  • Privacy and security

    Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of registration. Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.

  • CURRENT COVID SITUATION - IMPORTANT INFORMATION

    Currently due to the COVID situation you are not required to come into the surgery to sign these documents, as long as you have been filled in the required information you will be registered. Once you have been registered you will get a text or email to confirm your registration. It can take upto 72 working hours to be registered, if you have not received a text or email in that time frame please send us an email on blackfriarsmedicalpractice@nhs.net . Please make sure not to call the practice unless it is urgent, please send any queries on ASKMYGP or email. Thank you

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Page last reviewed: 14 September 2023
Page created: 13 January 2021