Child (under 16yrs old) New Patient Registration Form

IMPORTANT:

  1. Apart from completing and submitting the form below, you still must complete the other remaining steps on How to Register with the Practice to become registered at the practice. Please ignore the final message  when you submit the form that tells you that you need to attend the surgery – this is NOT required.
  2. Some patients have found that are unable to submit the form as they get a Recaptcha – Timed Out Error message. We have reported this to our website provider. If you experience this problem, please take Screenshots of EACH completed page of the form and email it to us at cloisterroad.surgery@nhs.net
  • Patient Details
  • Health Information
  • Further Information
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Patient's Details

About You (Parent/Guardian)

Mobile number for text message reminders.

Carers Information

eg. someone who is ill, frail, disabled, has mental health/emotional support issues or substance misuse
eg. family member, friend or neighbour
Preferably a mobile number
eg. Wheelchair, hearing aid, braille, lip reading, sign language etc.

Ethnic Origin

Medical Records

Please help us trace your previous medical records by providing as much of the following information as possible.

If you are from abroad

Please include dates/years.