New Patient Registration - Children up to 16 years

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 boundaries.

Patient's Details

Which practice do you wish this child to register with?
Child's Gender
Who else lives in this household? Please tick all those that apply.
Do you consent to us leaving messages about this child on this number?
Do you consent to us leaving messages about this child on this number?
Do you consent to receiving text messages about this child to this number?
Do you consent to receive emails to this address?

If this child is from abroad

Registering with the NHS for the first time in the UK

If this child is returning from abroad

Previously been registered with the NHS in the UK

If you need your doctor to dispense medicines and appliances for this child

Please select one option


Previous Details

Health History

Has your child had any serious illnesses or operations?
Does your child have a disabilty or chronic condition?


Is your child on any regular medication?

if you have a list from your previous GP please give us a copy

Is your child alergic to any medication?

Does your child have contact with any of the following?

A hospital specialist?
A health visitor?
A social worker?
Any other health professionals?
Has your child ever been under a Child Protection Plan?


It is important that your child’s immunisations are kept up to date.  A current photocopy of the immunisation history will help us to maintain their immunisation record; we can take a photocopy of this at reception.  If this is not available then please list below.


1st Diphtheria, Tetanus, Whooping Cough, Polio, Hib , rotavirus*

Aged 2m

2nd Diphtheria, Tetanus, Whooping Cough, Polio, Hib, rotavirus*

Aged 3m

3rd Diphtheria, Tetanus, Whooping Cough, Polio, Hib

Aged 4m

1st Pneumococcal

Aged 2m

2nd Pneumococcal

Aged 4m

1st Meningitis C

Aged 3m

Hib/ Meningitis C

1st Measles, Mumps, Rubella (MMR)

Booster Pneumococcal

Aged 12-13m

Booster Diphtheria, Tetanus, Whooping Cough, Polio

Booster Measles, Mumps, Rubella (MMR)

Aged 3y 4m

*rotavirus included since 2012

Do they need an interpreter or sign language support?
Please specify the ethnic group you consider your child belongs to:

Request for Proxy Access to GP Online Services (Parent/Guardian)

I/We                                                                      request Rothschild House Surgery give me proxy access to                                                                          ’s online services as indicated below.

I/We wish to have access to the following online services (please tick all that apply)

I/We                                                                      request Rothschild House Surgery give me proxy access to       wish to have online access to the services ticked in the boxes above for

I/We understand my/our responsibility for safeguarding medical information and I/We understand and agree with the following statements:

The Patient

The Parent/Guardian(s) (These are the people seeking proxy access to the patient’s online records, appointments or repeat prescriptions).

Understanding your records

Your records are written to help medical people look after you and so in some cases, you may not understand everything you see. If you find anything difficult to understand, as well as talking to your doctor or nurse, you can go to the NHS Choices website by using this link NHS Choices is the NHS website for patients so you can look for information on illnesses, improving health and to find NHS services in your local area.


Other websites frequently used to search for information on illnesses and test results are Patient – and Lab Test Online UK – Although these are not owned or checked by the NHS, other patients have found them useful.


A few things to think about

There are a few things you need to think about before registering for online records. On very rare occasions

  • Your GP may not think it in your best interest for you to look at your GP records online. If this happens, your GP will discuss their reasons with you. It is up to your GP to decide if you should be allowed access to your online records.

  • You may see your test results before your doctor has spoken to you about them. This may be when you cannot contact your surgery, or when your surgery is closed. This means you will need to wait until an appointment is available to talk to your doctor.

  • Information in your medical records might need correcting. If you find something you think is not correct, you should contact your surgery. The staff will be able to answer your questions and set things right when needed. Please bear in mind that you cannot change the record yourself.

  • There may be information in your medical records that you did not know was there or that you had forgotten about, such as an illness or an upsetting incident. If you see anything you did not know about that worries you, please speak to your surgery and they will discuss this with you.

  • If you see someone else’s information in your record, please log out immediately and let your surgery know as soon as possible.


If you have questions about any of the above points, please talk to your surgery and they will be able to advise you further.

Information for new patients: about your Summary Care Record

Dear patient,


If you are registered with a GP practice in England, you will already have a Summary Care Record (SCR), unless you have previously chosen not to have one. It will contain key information about the medicines you are taking, allergies you suffer from and any adverse reactions to medicines you have had in the past.

Information about your healthcare may not be routinely shared across different healthcare organisations and systems. You may need to be treated by health and care professionals who do not know your medical history. Essential details about your healthcare can be difficult to remember, particularly when you are unwell or have complex care needs.

Having a Summary Care Record can help by providing healthcare staff treating you with vital information from your health record. This will help the staff involved in your care make better and safer decisions about how best to treat you.


You have a choice


You have the choice of what information you would like to share and with whom. Authorised healthcare staff can only view your SCR with your permission. The information shared will solely be used for the benefit of your care.

Your options are outlined below; please indicate your choice on the form overleaf.


  • Express consent for medication, allergies and adverse reactions only. You wish to share information about medication, allergies for adverse reactions only.


  • Express consent for medication, allergies, adverse reactions and additional information. You wish to share information about medication, allergies for adverse reactions and further medical information that includes: your illnesses and health problems, operations and vaccinations you have had in the past, how you would like to be treated (such as where you would prefer to receive care), what support you might need and who should be contacted for more information about you.


  • Express dissent for Summary Care Record (opt out). Select this option, if you DO NOT want any information shared with other healthcare professionals involved in your care.


If you chose not to complete this consent form, a core Summary Care Record (SCR) will be created for you, which will contain only medications, allergies and adverse reactions.

Once you have completed the consent form, please return it to your GP practice.

You are free to change your decision at any time by informing your GP practice

Summary Care Record patient consent form


Having read the above information regarding your choices, please choose one of the options below and return the completed form to your GP practice :


Yes – I would like a Summary Care Record


No – I would not like a Summary Care Record

Supplementary Questions

Only complete the below if you have ticked 'I am not ordinarily a resident in the UK'.

Anybody in England can register with a GP practice and receive free medical care from that practice.


However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK.


Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.


More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice. Alternatively for more information go to


You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.


The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me.


A parent/guardian should complete the form on behalf of a child under 16.

Please select one of the following statements

European Economic Area (EEA) Country

For a list of EEA countries visit:

Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?

Thanks for submitting!