Child Registration Form (Under 18)

Welcome to the Crown Medical Centre. To help us provide you with the best possible service, we would be very grateful if you would take the time to answer the following questions. Thank you.

Patient details:

Title

Surname

Forenames

Previous surname/s

Date of birth

NHS number

Gender

Gender at birth

Town and country of birth

Address

Postcode

Contact number/s

Please help us trace your previous medical records by providing us the following information:

Your previous address in the UKPlease note, do not leave this blank as we are therefore unable to register you without this information. (Unless N/A)

Address of previous GP practice:Please note, do not leave this blank as we are therefore unable to register you without this information. ( Unless N/A)

If you are from abroad:

Your first UK address where registered with a GPPlease note, do not leave this blank as we are therefore unable to register you without this information. (Unless N/A)

If previously resident in the UK, date of leaving

Date you first came to live in UK

Next of kin:

Full name

Relationship

Address (if different from above)

Contact number

Ethnicity data

Please specify

If other, please specifyIf not applicable, just state N/A

Please state your first language

Women only:

What contraceptive method do you use? If any?

Pill

Depo

Coil

Implant

Date of replacement due (coil and implant only)

Medical history:

Past medical HistoryPlease state any on-going illnesses or any significant past illnesses, operations or accident and the years they happened or started.

Current medicationPlease list medications that you are taking at the present time and the dosage.

AllergiesPlease state any allergies that you have and the date which they started.

Lifestyle information:

Weight

Height

Do you smoke?

Do you drink alcohol?

Vaccination History:

Please give us the date of you last vaccinations

Tetanus vaccination

Polio vaccination

Shingles vaccination

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to The Crown Medical Centre • Venture Way, Taunton, TA2 8QY.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.