Register a child as a patient form

Complete the online form below to register a child as a patient at the surgery. You will need to provide a form of ID to prove that you’re their parent or guardian.

Child's full name

Date of birth

Sex

Male

Female

Home address

Postcode

Parent/Guardian's full name

Contact number

Email address

NHS No.

An NHS number is a 10-digit number, like 485 777 3456. If known, please enter your NHS number in the field below. You can find more information on the NHS website

Allergies (if any)

Current medication (if any)

Previous GP (if known)

I consent to NHS medical care for my child

Parent/Guardian's Signature

Please write your full name

The day of submitting the application