Title: Pre-registration Form
Author: Emis2000
Last saved by: The Vale
Company: EMIS

Pre-registration form for patients under 18 years old
(Please Note: In order to register a child at least one parent or guardian must also be registered at the practice)
Child’s Details
First Name		Surname	
Ethnicity (please circle)
White British	White Irish	White other	White/Black Caribbean
White/Black African	White/Asian	Mixed other	British Indian
British Pakistani	Bangladeshi/British	Other Asian	British Caribbean
African	Other Black	Chinese
Other	Child’s Country of Origin?	
If from overseas on what date did the child enter the country? 	
Parents’ Details
Mother’s FULL Name		Date of Birth	
Father’s FULL Name		Date of Birth	
Which parent has parental responsibility?	Mother	☐	Father	☐	Both	☐
Note: This is always the mother and also the father if parents were married when the child born and the father is named on the Birth Certificate and the child was born after 1^st December 2003 in England and Wales. The father does not lose parental responsibility after a divorce.
Address of Person with Parental Responsibility (ONLY if different from the child’s address)

Details of any Siblings
Full Name		Date of Birth	
Full Name		Date of Birth	
Full Name		Date of Birth	
Full Name		Date of Birth	
Details of any other Household Members (e.g. lodgers, nanny, relations etc.)
Full Name		Date of Birth	
Full Name		Date of Birth	

Name and Address of current School or Nursery	

1. Does the child have a current social worker?	Yes	☐	No	☐	
If so please give their name and address	
	
2. Were there any previous social workers for this child?	Yes	☐	No	☐
If so please give their names and addresses (or boroughs if addresses are not known)

3. Is the child in a care home or fostered?	Yes	☐	No	☐	
If so please give the name and address of this home or the home in which they are fostered

4. Has the child had any major illnesses or operations, chronic illnesses such as Asthma or any disabilities? 	Yes	☐	No	☐
If so please give details	

5. Has the child had any admissions or A&E attendances in the last year?
	Yes	☐	No	☐
If so please give the dates and reasons	

6. Is the child currently taking any medication?	Yes	☐	No	☐	
If so please give details	

Is the child allergic to any medicines?	Yes	☐	No	☐	
If so please give details	
	
Please bring the Red Book.
Do you agree to immunise the child?	 Agree	☐	Refuse	☐
Signature		Date	
	Form version Pre Reg Child 140618 BHO