Coachmans Medical Practice
Reception staff Initials:
New Patient Registration Form (Child) 0-16
We would like to invite you to complete this form in FULL; your registration
may otherwise be delayed.
The information provided on this questionnaire, forms what is called a New Patient
Health Check. Should, however, you wish to see a clinician for a face to face
consultation please make an appointment.
DATE OF NEW
REGISTRATION:
DATE OF BIRTH:
SURNAME:
FIRST NAME
TELEPHONE NO: (Home)
(Mobile contact telephone number)
Contact Email Address:
I confirm that you may contact me by e-mail or SMS text messages:
I do not wish to be contacted by e-mail and or SMS text messages:
MOTHERS FULL NAME:
LEGAL GUARDIANS FULL NAME:
PLAYSCHOOL/SCHOOL ATTENDED:
(Please note if your child is educated at home please state)
Your Personal Information
Due to Government Policy we are obliged to ask you the following:
Please state your first spoken language if not English
…………………………………………………….
What is your ethnic group? (Please choose only ONE section from A to E and tick
the appropriate box)
A: WHITE
 British
 European
Vietnamese
C: BLACK or BLACK BRITISH
 Caribbean
 African
B: MIXED
D: ASIAN or ASIAN BRITISH
 White and Black Caribbean
 Indian
 Arabic
 White and Black African
 Pakistani B
 White and Asian
 Bangladeshi
E: EASTERN ASIAN
 Chinese

F: MIDDLE EASTERN
 Iranian
 Turkish
 Any other group not stated above?
……………………………………………………………………………..
 I do not wish to state my ethnic group
Help us to help you:
Do you or your child have any communication needs?
Visual impairment
Hearing impairment
Please state any medical history i.e. illnesses, operations with dates if
possible that you feel the practice should be aware of:
Current prescribed medication:
Many prescriptions can now be sent electronically, please nominate a
pharmacy to collect your medication from:
Do you have any allergies we should be aware of?
CONFIDENTIAL
OPT-OUT FORM
Request for my clinical information to be withheld
from the Summary Care Record
If you DO NOT want a Summary Care Record please fill out the form and
send it to your GP practice
A. Please complete in BLOCK CAPITALS
Title...................................... Surname / Family name …………………………..………………...
Forename(s)...............................................................................................................................
Address.......................................................................................................................................
Postcode .................................. Phone No....................................... Date of birth………………
NHS Number (if
known)........................................................................................................................................
__________________________________________________________________________
B. If you are filling out this form on behalf of another person or a child, their GP practice will
consider this request.
Please ensure you fill out their details in section A and your details in section B
Your name........................................................................................... Your signature
………………………..
Relationship to patient ......................................................................... Date ...........................
_________________________________________________________________________________
What does it mean if I DO NOT have a summary Care Record?
NHS healthcare staff caring for you
questions
may not be aware of your current
discuss
medications, allergies you suffer from
please:
and any bad reactions to medicines
Summary Care
you have had, in order to treat you
Information Line
safely in an emergency.
local Patient
Liaison Service
Your records will stay as they are now
If you have any
with information being shared by letter
or if you want to
e-mail, fax or phone
your choices,
phone the
Record
0300 123 3020;
contact your
Advice
(PALS); or
contact your