Child Patient Registration

Child Patient Registration

To access our services, your child will need to be registered as a patient with us.

The registration process is quick and easy. Fill out the form and our admin team will process your registration.

Please check the catchment area before registering.

Check the catchment area

Emergency contact

  • Patient Details
  • Next of Kin
  • Additional info
  • Housing

Patient Details

Surname

First Name(s)

Date of Birth

Gender

Child's Main Address

Who has parental responsibility?

Someone else (please state name and relationship to child)

Mother's details

Mother's Name

Mother's Telephone

Mother's Address (if different from Child's)

Father's details

Father's Name

Father's Telephone

Father's Address (if different from Child's)

Next of Kin's details

Name

Address

Telephone (Home)

Telephone (Work)

Telephone (Mobile)

Additional info

If your child is under 1 years of age, were they premature?

Is your child home schooled?

If no, which school did they attend?

Names of previous school's (if any)

Has your child ever been suspended or excluded from school

Name of Health Visitor/ School Nurse (if known)

Has your child ever been subjected to a Child Protection Plan?

If yes, when?

Has your child ever been a

Housing

What type of housing does your child live in?

House or Flat (if flat which floor?)

Are there any housing problems (overcrowding, damp)?

Please list all the people that share the house with the child and their relationship to the child. If they are a child please state their age.