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Child new patient registration

New Patient Registration (Child V2) – Hall Green

Patient’s Details

Title *
Please use this date format: DD/MM/YYYY.
What gender does the child identify with? *
Does their gender identity differ from that which was assigned at birth? *
Please state their sexual orientation: *
Do they currently have a fixed address? *

Hall Green Health will continue to register the child but they will put the address as the surgery’s address. As soon as the child has an address please let us know as it helps us to get hold of them in regards to their care.

Any responses we send will go to this email address.
Can we contact you by text? *
Can we contact you by email? *
Has the child ever been registered with Hall Green Health before? *
Do they have any information or communication needs such as large print or specific coloured paper? *
Are they happy to travel to the surgery if necessary? *
How would you define their mobility? *

Ethnicity

Please specify the ethnic group you consider they belong to: *
*
*
*
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Do they speak English? *
Do they read English? *
Is English their first language? *
Do they need an interpreter? *

Additional Information

If your child is under 1 year of age: were they premature?
Is your child home-schooled?
Has your child ever been suspended (received a fixed-term exclusion) or permanently excluded from school?
Has the child ever been the subject of a Child Protection Plan?
Has your child ever been a “Looked After” child (i.e. in Foster Care or in a Children’s Home)?

Housing

What type of residence does the child live in?
What type of building does the child live in?
Please list all the people (children & adults) that share the house with the child and their relationship to them:

Please select appropriately:
Are they registered at this practice?
Does the child live with anyone else?

Please select appropriately:
Are they registered at this practice?
Does the child live with anyone else?

Please select appropriately:
Are they registered at this practice?

Emergency Contact

Are they the child’s Next of Kin? *
Do you give us permission to discuss their medical records with them? *

Parents Details

Who has parental responsibility? Please tick where appropriate:

Allergies

Do they have any allergies? *

Previous Details

Have you previously lived at another UK address? *
Please include postcode.
Have you been previously registered with another surgery in the UK? *

If you are from abroad

Please use this date format: DD/MM/YYYY.

If you are under 3 years old you must have a named health visitor. If you do not have one please call the health visitors on 0121 466 4820.

If you are returning from abroad

Previously been a resident in the UK

Please use this date format: DD/MM/YYYY.
Please use this date format: DD/MM/YYYY.

Carers

Do they have a carer? *
Do you give us permission to discuss their medical record with their carer?
Are they a carer for someone? *