CHILD QUESTIONNAIRE

Rutland House Surgery Health Questionnaire for Newly Registered Child Patients

Personal Details

Consent to receive text messages via mobile re. child

Consent to receive text messages via mobile re. child

Please indicate ethnicity:

Please indicate ethnicity:

Child's Medical History

Child's Medical History

Has your child had any of the following illnesses? (Please check all that apply) *

Has your child had any hospital admissions for serious illnesses or accidents?

Has your child had any hospital admissions for serious illnesses or accidents?

Due to Child Protection guidelines, children will not be registered without a parent/legal guardian also being registered at the practice.

A birth certificate may be asked for to confirm who has parental responsibility for a child.

Do you consent for another adult (grandparent, au pair) to seek medical advice/treatment for your child?

Do you consent for another adult (grandparent, au pair) to seek medical advice/treatment for your child?

WE REQUIRE AN UP TO DATE IMMUNISATION HISTORY OF CHILDREN UP TO THE AGE OF 5 UPON REGISTRATION

PLEASE BRING YOUR RED BOOK TO THE SURGERY

Send Your Request

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