Children (8 weeks - 15 years old) - New Patient Registration Form & Questionnaire

Thank you for choosing to register with the Keats Group Practice. To ensure your child's registration can be fully completed and that their medical record is kept up-to-date, please complete this form as accurately as possible. Do ensure that you have your child's immunisation history available when completing the form.

Last Updated: 28/01/2022

Child's Personal Details
















Child's Ethnicity



Parent / Guardian (s) Details






Previous GP


Next of Kin


Contacting You

Please note that Proxy Online Access, to some aspects of the child's medical record can be requested for children under the age of 12. Further information and application can be found on our website.

Signature



Child's Medical History







Child's Immunisation History

It is important that we have an up-to-date record of your child's vaccinations to ensure your child is fully immunised in accordance with the UK Immunisation Schedule










Immunisations of Children Aged 12 -15 Years old

Please move to the next section if not applicable 





Family Medical History



Additional General Details