New Patients

New Patient Registration

To register with us as a new patient, please complete the registration form below. We aim to process your registration within 48 hours.

PLEASE NOTE: Please do not complete this form if you are already registered with us – this form is for New Patients Only.

Looking for Online Services? If you are already registered with us, you can download and use our Dr. iQ practice mobile app today.


*NEW* New Patient Registration Form

Personal Details

Complete the registration form below with the details of the child

Please use this date format: DD/MM/YYYY
Please select your sex as recorded at birth.

Language Support

Contact Details

Have you lived at your current home address for more than 3 years?
Please use this date format: DD/MM/YYYY
 
 
Next of Kin

Child Under 16 Registration

Protection Plan/Foster Care Information
Parents/Carers Details

Mother/Carer
Father/Other Carer
Child's School Details
Please advise if the child has had any of the following immunisations (you can check your child's red book).

Age due: 8 weeks

Age due: 12 weeks
Age due: 16 weeks
Age due: 12 months

Age due: 3 years 4 months or soon after

Our ethos is to keep people healthy through screening and immunisation programmes. We actively encourage your child to follow the routine immunisation schedule

Your Information

Summary Care Record

A summary care record (SCR) is an electronic summary of key health information. It will hold limited essential information derived initially from your GP record. This will include medication, adverse reactions and allergies. If you wish to know more information regarding the system and the benefits please ask reception. Alternatively, visit the website: www.nhscarerecords.nhs.uk or call 0845 603 8510

Please write your name or parent/carer for under 16s
Sending