* Has
your child ever registered
with this practice before?
Yes
No
* Child's title:
Mr
Miss
* Family
name/Surname:
* Child's first names:
* Child's date of birth:
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
Child's
NHS Number:
* Child's gender
at birth:
Male
Female
* Town and country of
birth:
CHILD'S HOME ADDRESS
Name of school/nursery:
Contact number at school/nursery:
Aditional details:
Parent/Carer Details (should be child's Next
of kin):
Is the parent/carer registered at Langworthy
Medical Practice? Yes
No
Carer's full name:
Relationship to child:
* Mobile phone number:
* Email address:
*
Confirm email address:
Do you give consent for us to
CONTACT YOU via text message or email?
*
Text/SMS: Yes
No
*
Email:Yes
No
You are giving permission for us to send you
appointment reminders, information regarding your
health care and clinic updates.
How would you prefer to be contacted?
Text/SMS
Email
Details of other Parent if different from next
of kin if registered with the practice:
*
Parent/Carer signature:
Child's Health Questionnaire
*
Is your child a Young Carer?
Yes
No
IMMUNISATIONS
It is important that we know the status of
your children's immunisations. Has your child
ever had the following vaccinations? Alternatively,
please attach them below.
If you have a list of your child's
immunisations, please attach it here:
Your child's registration may not be completed
without this information.
HEIGHT:
cm
WEIGHT:
kg
*
Is your child known to Children’s
Services/Social Services?
Yes
No
If Yes, what is the name of your Social
Worker?
* Summary Care Records
Summary Care Record (SCR) - this is an electronic
record which contains information about the
medicines you take,
allergies you suffer from and any bad reactions to
medicines you have had. Having this information
stored in one place
makes it easier for healthcare staff to treat you in
an emergency, or when your GP practice is closed.
I agree to opt in
I do NOT agree to opt in
* Important Information
It is practice policy to share information that is
recorded on your clinical record with other clinical
staff that you are under
the care of to ensure the
best care is provided to you. For further
information please ask for an information leaflet
or
visit www.nhscarerecords.nhs.uk/carerecords .
Your record will be automatically setup to be shared
with the other Health Care organisations. These
organisations
will only be able to view your shared record if they
are actually providing you with care. However, you
have the right
to ask your GP to disable this function or restrict
access to specific elements of your record. This
will mean that
the information recorded by your GP will not be
visible at any other care setting
Do you consent for us to share your medical
records with other medical service
you may be using
i.e. District Nurse Teams, Podiatry or Dieticians?
I agree to opt in
I do NOT agree to opt in
ONLINE ACCESS REGISTRATION
Would you like to have access to the following
online services?
Booking appointments:
Yes
No
Request repeat prescriptions: Yes
No
Organ Donor Registration
If you are interested in
becoming an organ donor,
please click this link
to go to the
organ donor registration page.
Blood Donor Registration
If you are interested in
becoming an blood donor,
please click this link
to go to the
blood donor registration page.
Please read the CampusDoctor
Privacy Notice.
The information you are submitting will be
sent encrypted to the medical practice over the Internet, which
still isn't 100% secure.
If you are worried about this you can
instead obtain a form from the medical practice that can be
filled in and delivered by hand.