Newborn Registration Form & Questionnaire

Thank you for choosing to register with the Hampstead Group Practice.

Please ensure you complete the details below as accurately as possible.

Last Updated: 04/05/2022

Child's Personal Details

A copy of your baby's birth certificate will be requested seperately

TITLE

SURNAME *

FIRST NAME (S) *

PREVIOUS SURNAME (IF ANY)

PLACE OF BIRTH (INCLUDING BOROUGH, IF LONDON) *

DATE OF BIRTH *

NHS NUMBER *

ADDRESS *

POSTCODE *

HOME NUMBER

MOBILE NUMBER *

EMAIL ADDRESS

IS THE CHILD REGISTERED DISABLED ?

Yes No

IF YES, PLEASE GIVE DETAILS OF THE DISABILITY:

Childs Ethnicity

ETHNICITY - PLEASE SPECIFY WHICH GROUP YOU CONSIDER YOUR CHILD BELONGS TO *

Arab

Asian / Asian British - Indian; Pakistani; Bangladeshi; Chinese

Other Asian Background - please describe below

Black/African/Caribbean/Black British

Other Black background - please describe below

Mixed / Multiple Ethnic Group - please describe below

White - Scottish/English/Welsh/Nothern Irish/British; Irish; Gypsy or Irish Traveller

White Other - please describe below

I do not wish to state

PLEASE DESCRIBE BELOW ANY OTHER ETHNIC GROUP OR BACKGROUND

Parent/Guardian (s) Details

PLEASE INDICATE WHO HAS PARAENTAL RESPONSIBILITY *

Mother

Father

Guardian

MOTHERS FULL NAME (SURNAME; FIRST NAME)

FATHERS SURNAME (SURNAME; FIRST NAME)

GUARDIAN'S FULL NAME (SURNAME: FIRST NAME), IF APPLICABLE

GUARDIAN'S RELATIONSHIP TO THE CHILD, IF APPLICABLE

Next of Kin

PLEASE GIVE NAME, ADDRESS, TELEPHONE NUMBER AND RELATIONSHIP OF NEXT OF KIN

Which relative?

Parent or Guardian Signature

I confirm that the information I have provided is true to the best of my knowledge

Signature *

Contacting You

Please note that Proxy Online Access, to some aspects of the child's medical record can be requested for children under the age of 12. Further information and application can be found on our website

DO YOU AGREE THAT YOU MAY BE CONTACTED FROM TIME TO TIME, VIA EMAIL AND/OR SMS, WITH PRACTICE NEWS, ADVICE ABOUT HEALTH AND/OR APPOINTMENT REMINDERS. *

Yes (recommended option)

Signature of Parent / Guardian

Signature *

DATE *

Newborn - SCID Screening (Heel Prick Test)

Complete if registering 0 - 8 weeks old

SCID screening is offered, at the time of the Newborn Heel

Prick test when baby is 5 days old. Please complete the information below as this will be needed before the baby has their 1st immunisation.

SCID SCREENING RESULT - A COPY OF THE RESULT WILL BE REQUESTED ONCE BABY HAS BEEN REGISTERED *

SCID Condition Not Suspected

SCID Condition Suspected

SCID Screening Undertaken - Awaiting Results

SCID Screening Declined

SCID Screening Not Offered

Childs Medical History

ALLERGIES (ANYTHING, INCLUDING MEDICINES)

HAS YOUR CHILD HAD ANY MEDICAL PROBLEMS IN THE PAST NEEDING HOSPITAL, SURGERY ATTENDANCE OR REPEATED VISITS TO THE DOCTOR?

Yes No

ANY CURRENT ILLNESSES FOR WHICH THEY ARE RECEIVING TREATMENT?

Yes No

IF YES, PLEASE GIVE DETAILS:

IS YOUR CHILD TAKING ANY PRESCRIBED MEDICATIONS / TABLETS?

Yes No

IF YES, PLEASE GIVE DETAILS BELOW, INCLUDING DOSE AND FREQUENCY OR INDICATE IF A COPY OF THEIR REPEAT MEDICATIONS CAN BE PROVIDED:

Family Medical History

IS THERE A FAMILY HISTORY, WITHIN IMMEDIATE FAMILY, OF ANY OF THE FOLLOWING?

Heart Attack, Angina or bypass surgery?

High Blood Pressure

Stroke / TIA

Diabetes

Asthma / COPD

Cancer (if selected, please include details of the site of cancer below)

IF ANY OF THE ABOVE SELECTED, PLEASE INDICATE WHICH IMMEDIATE FAMILY MEMBER(S)

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Newborn Registration Form & Questionnaire

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