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

Fields marked REQUIRED are compulsory. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Your details will be held at the surgery for a limited period of time. You are required to present in person to sign your registration form and provide proof of your address. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register.

Last Updated: 15/02/2023

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 *

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

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