Muswell Hill Practice New Patient Registration Form (GMS1) + Under 15's Health Questionnaire

Before registering a child, please make sure you are eligiable to register. We are only able to register children under 5 within our catchment area.

For clinical safety reasons, we can only register a child when at least one parent/guardian is registering with us too, preferably both.

After submitting the form, please allow up to 10 working days for the form to be processed.

Initial Questions

I am completing this form on behalf of... *

Today's Date *

State your relation to them:

Complete Registration

Thank you for completing your registration form, please be aware that forms take 2 weeks to process, after which you can book an appointment. If you are registering as a household, each person must complete their own registration form. Registration forms for adults and babies can be found on our registrations page.

I understand that my registration will take 2 weeks to process, after which I can book an appointment. *

Yes No

Patient's Details

Please help us trace the patients previous medical records by providing the following

NHS number (Your previous doctors surgery can provide you with this) *

Title *

Surname *

First name(s) *

Previous Surname

Date of Birth *

Birth Hospital/Borough *

Birth Town (If you were born in London, please include the hospital or borough they were born in) *

Birth Country *

Sex *

Male

Female

Address *

Postcode *

Telephone *

Email Address *

Contact with the Surgery

Important questions to help you use our services - we will use these details to contact you about services for the child you are registering

Do you want to receive text reminders to mobile telephones about appointments and other clinical services? *

Yes No

If yes, please provide your email address?

Ethnicity and languages

Please select the patient's ethnic group *

What is their main language *

Other spoken languages

Do you need an interpreter?

Yes No

Please help us trace their previous medical records by providing the following

Patient's previous address in UK *

Name of previous GP while at previous address *

Address of that Doctor

If you are from abroad

Patient's first UK address where registered with a GP

If previously resident in UK, date of leaving

Date you first came to live in UK (DD/MM/YYYY) *

Next of Kin

Please tell us who to contact in case of an emergency

Title *

Name *

Contact number *

Relationship to the patient *

Household Information

Name of child's School/Nursery *

Name and date of birth of siblings:

Name and date of birth of other household members *

Who has parental responsible for the patient? *

Please state the relationship: *

Is the child a 'looked after child'? *

Yes No

Has your child ever been subject to a Child Protection plan? *

Yes No

If a social worker is/has been involved in the past, please state the name of the social worker:

Medical History

Please list any serious or chronic illnesses, operations or disabilities:

Please give the reasons and details of hospital admissions and A&E attendances in the last year:

Does the child take any repeat medications? Please list below:

Immunisations: please enter date received

Please enter the date of immunisations and where it was administered (previous GP name, abroad, etc). DtaP = Diptheria/Tetanus/Pertussis, HiB = Haemophilus Influenza Type B, MenC = Meningitis C, MMR -= Measles/Mumps/Rubella

1st DtaP/IPV/HiB/HepB *

2nd DtaP/IPV/HiB/HepB *

3rd DtaP/IPV/HiB/HepB *

1st Rotavirus *

2nd Rotavirus *

1st Men B *

2nd Men B *

3rd Men B *

1st Men C *

2nd Men C *

3rd Men C *

1st Pneumococcal *

2nd Pneumococcal *

3rd Pneumococcal *

1st MMR *

2nd MMR *

HiB/Men C booster *

Pre School Booster *

BCG *

1st Hep B *

2nd Hep B *

3rd Hep B *

4th Hep B *

1st HPV *

2nd HPV *

Td/IPV *

Men ACWY *

Other Immunisations *

Summary Care Record

Children under 16 will automatically have a Summary Care Record containing details of current medications, allergies and previous reactions to medicines, to ensure those caring for them have enough information to treat them safely. This record is created for them unless their parent or guardian chooses either to notify us that they would like their child to have an enriched Summary Care Record (with other information agreed with the GP Practice to be included) or to opt out. If you are the parent or guardian of a child under 16 and feel that they are old enough to understand, then you should make this information available to them.

Your Summary Care Record will be available to authorised healthcare staff providing your care anywhere in England, but they will ask your permission before they look at it. This means that if you have an accident or become ill, the doctors treating you will have immedictae access to important information about your health.

If you know that a Summary Care Record was created for you by your previous GP Practice, we would be grateful if you could confirm your current choice.

For more information you can talk to the Patient Advice and Liaison Service (PALS) (0800 587 4132), GP practice staff, or visit the NHS Digital website here.

You can choose not to have a Summary Care Record and you can change your mind at any time by informing your GP practice.

Childred under 16 will automatically have a Summary Care Record. If you would like your child to have an enriched record or to opt out, please pick from the options below:

I would like my child to have an enriched Summary Care Record (e.g. significant illnesses and health problems, past operations and vaccinations, 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)

I would like to opt out of my child having a Summary Care Record

If you are filling out this form on behalf of another person or a child, please fill your name and your relationship to the patient below

Complete Registration

Signature on behalf of patient *

Please be aware that forms take 2 week to process, after which you can book an appointment. Check below to confirm you understand this. *

Yes No

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Page last reviewed: 16 May 2025
Page created: 10 July 2020

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Muswell Hill Practice New Patient Registration Form (GMS1) + Under 15's Health Questionnaire

Muswell Hill Practice New Patient Registration Form (GMS1) + Under 15's Health Questionnaire

Further Information