Child Registration Form - Living Well Partnership

You have 30 minutes to complete this form before data will be cleared from it. If you don't have the child's medical history information to hand please find this then refresh this form before starting.

Step 1 of 2

This registration form should be used to register a child aged 15 years or younger. Please note that in order to register your child at least one parent at the same address must be registered with the partnership, if applicable, please use the adult registration form.

Our registration forms are secure, online and confidential and all information is held on NHS servers.

Applications typically take two working days to process. If you have a more immediate enquiry and are not yet registered please contact us by phone on 02380 449913.

Child's details

Title

Surname

First name(s)

Date of Birth

Gender at birth

NHS Number

Address

Postcode

Previous Address

Previous Postcode

Previous GP Surgery Name

Previous GP Surgery Address

Does your child have a religious affiliation?

Yes

Please give details

Ethnic Background

Country of birth

Date of entry to UK

First Language

Do they need a translator?

Yes

Your details

Parent/Guardian 1

Please note that the mobile phone, home phone and email details for Parent/Guardian 1 will be listed as the main contact details on the child’s records.

Name

Address same as child?

Yes

Address

Postcode

Phone number

Additional number

Relationship to child

Parent/Guardian 2 (if applicable)

Name

Address same as child?

Yes

Address

Postcode

Phone number

Additional number

Relationship to child