Child 0-16 years Registration Form New Patient Registration Form – Child 0-16 years Childs NameDate of Birth MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country PhoneConsent to text Yes Optional No Optional NB: are any of the above details protected information? If so please indicate below OptionalDoes the child live with someone who is not their parent? Please state relationship OptionalParent/Guardian of above child OptionalSchool/Nursery attended OptionalIs the child a young carer? Yes Optional No Optional Who do they care for? OptionalPlease list any other people who live at this address and their relationship to child OptionalPlease list any serious illnesses or operations and the year (if known) Add RemovePlease state ethnic originSpoken languageIs the child under the care of any hospital? If so which hospita and specialist? OptionalPlease list any allergies Add RemoveDiphtheria/Tetanus/Pertussis/Polio/HIB/Hep B Yes Optional No Optional Measles/Mumps/Rubella (MMR) Yes Optional No Optional Meningitis Yes Optional No Optional Pneumococcal (PCV) Yes Optional No Optional Do they take any regular medications or treatments? Please state dosage below OptionalWhich pharmacy would you like your prescription to be sent to? OptionalDoes the child have any special needs/learning disabilities? If so please give diagnosis OptionalReasonable Adjustments are changes we (and other organisations involved in your care) can make, so that care is as accessible for you as for people who do not have a disability or impairment. Some examples of reasonable adjustments are listed below. Please tick if these apply to you or use other if there is something else you would like help with. If you would like and support or help with completing this section, please ask a member of the team. When I attend my health appointment I may need: My carer to stay with me Optional Wheelchair friendly access Optional Appointments at quiet times Optional Support with consent to treatment Optional Help when my name is called for my appointment Optional Easy read information Optional Arrange my appointments through my parent/carer – Please add name and contact number below Optional You to speak slowly and clearly so I can understand Optional You to allow me time to answer your questions Optional I am unable to read Optional No reasonable adjustments required Optional Other please state OptionalSignatureDeclaration I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above. SignatureDate MM slash DD slash YYYY Name First Last