Under 16 New Patient Registration

If you would like to register with the practice, please use this form.

To register a new patient you will need to live within our practice boundary.

Please give us details of all their immunisations. If they are under five years old, please also contact the health visitor to make sure that they benefit from all the preventative facilities available.

U16 New Patient Registration - Chobham & West End

U16 New Patient Registration - Chobham & West End

The DoH have requested that the practice records the ethnicity of all newly registering patients. Are you willing to have this information recorded? *
What is your ethnicity?

Personal Medical History

Please mention if there was any complications at birth.

Family History:

Has any first-degree relative (parent/brother/sister) ever died before age 65? If so, please give details

Immunisations:

Please give dates of all his/her vaccinations.

Diphtheria / tetanus / whooping cough and polio

Hib (haemophilus influenzae)

Meningitis C

MMR (measles / mumps / rubella)

Other Vaccinations

This practice has joined the national Summary Care Record programme which enables each patient to have a summary of their key medical information held securely on the NHS central database, known as the NHS Spine. This summary record could be used in an emergency if you needed treatment when access to the medical record held by your GP was not available; for example if you call the doctor out of hours. You will always be asked to give permission for this record to be viewed and you have the right to decline.

Please indicate below whether you would like to have your own Summary Care record by indicating your decision below. A full explanation of each choice follows.

My decision: *
  • A Summary Care record will be created for you from the details held on our GP clinical system and will contain:
    • Any record we have of your current repeat medication, any acute medication (one-offs e.g. antibiotics) and any recently discontinued medication
    • Any record we have of adverse reactions to medication
    • Any record we have of your allergies
  • A Summary Care Record will be created for you containing the details itemised above in 1, plus important additional information you and your GP agree would be useful. (e.g. Diagnoses - Asthma, Diabetes etc.; Pacemaker, End of life care etc.) Please discuss this with your GP at your next visit.
  • A note will be made in your records that you do not wish to have a Summary Care Record. Please note that if you attend A&E or if you need emergency treatment when the GP Practice is closed the clinicians treating you may not have access to key information to help them give you the most appropriate treatment.