Patient Registration Form

Patient

Patient's Official Name ie the name on their birth certificate or passport *

Patient's Preferred Name

Date of Birth *

Sex assigned at birth *

Gender if different to sex assigned at birth

Address *

Postcode *

Parental Responsibility Contact Details

Name of Main Contact With Parental Responsibility *

Title *

Home Address (If Different to Patient)

Postcode

Main Contact Number *

Alternative Number

Email Address (That We Can Send Medical Reports, Invoices To, if Needed) *

We need all contact details who have parental responsibility of the patient. Please provide their details below. If you wish to add any notes, please use the Notes section at the end of the form. If there are further contacts you would like included, please use the Notes section at the end of the form to provide the details in the same format as below:

Title (Mr, Mrs, Ms, Dr, etc)

Name

Relationship to Patient

Relationship to Main Contact

Background Information of Relationship to Main Contact

Contact Number

Email Address

PATIENT’S GP DETAILS

Name of GP

Surgery Name *

Address *

Postcode *

Telephone Number *

PATIENT’S EDUCATION

Name of Educational Establishment

If Home educated, or not in education, please put N/A for Postcode, Address, Name of Contact, Tel Number, Email Address.

Address of School

Postcode

Name of Contact

Contact Number

Email Address

PAYMENT DETAILS

We are a self-funded practice. Please refer to our Fee Transparency Letter regarding claiming against your medical insurance company if you have medical insurance

Please Provide Contact Details of the Person Paying if Different From ‘Main Contact’ Details Above.

How Did You Hear About Us?

What Is Your Main Spoken Language?

ALL OF OUR CLINICS ARE HELD IN VENUES ON FLOORS THAT ARE EASILY ACCESSIBLE. PLEASE INFORM HEALTHCARE4KIDS IF YOU HAVE MOBILITY DIFFICULTY AND WE WILL ENSURE YOU ATTEND A CLINIC THAT MEETS YOUR NEEDS.

BY COMPLETING THIS REGISTRATION FORM, YOU ARE AGREEING TO OUR PRIVACY POLICY and terms and conditions on our Fee Transparency Letter.

Main Contact Name *

Date *

Notes for Additional Information