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

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.

  • Child's Personal Details

    Date of Birth
    For example, 15 3 1984
    Is the child registered disabled ? (optional)

  • Child's Ethnicity

    Ethnicity - please specify which group you consider your child belongs to

  • Parent / Guardian (s) Details

    Please indicate who has parental responsibility

  • 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.

    Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders.

  • Signature

    Date
    For example, 15 3 1984

  • Child's Medical History

    Has your child had any medical problems in the past needing hospital, surgery attendance or repeated visits to the doctor? (optional)
    Any current illnesses for which they are receiving treatment? (optional)
    Is your child taking any prescribed medications / tablets? (optional)

  • 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. 

    8 weeks old Immunisations Given
    Date of 1st Immunisations - 8 weeks old
    For example, 15 3 1984
    12 weeks old Immunisations Given
    Date of above immunisations - 12 weeks old
    For example, 15 3 1984
    16 weeks old Immunisations Given
    Date of Immunisations Above - 16 weeks old
    For example, 15 3 1984
    1 Year Old Immunisations (Given on or after child's 1st birthday)
    Date of Above Immunisations - 1 year old
    For example, 15 3 1984
    2 and 3 Years Old (optional)
    Date above vaccination given (optional)
    For example, 15 3 1984
    Three years four months old or soon after Immunisations Given (Pre-school booster)
    Date above Immunisations Given - Pre-school
    For example, 15 3 1984

  • Immunisations of Children Aged 12 -15 Years old

    Please move to the next section if not applicable 

    HPV - 1st dose Given (optional)
    For example, 15 3 1984
    HPV - 2nd Dose Given (optional)
    For example, 15 3 1984
    Tetanus, diphtheria and polio Td/IPV - Given aged 14 (School Year 9) (optional)
    For example, 15 3 1984
    Meningococcal groups A, C, W and Y disease MenACWY - Given aged 14 (School Year 9) (optional)
    For example, 15 3 1984

  • Family Medical History

    Is there a family history, within immediate family, of any of the following? (optional)

  • Additional General Details

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Page last reviewed: 31 January 2023
Page created: 16 April 2020