Unimed Child (Age 0-16) New Patient Registration

Patient’s Details

Title *
Please use this date format: DD/MM/YYYY.
Sex *
How long will you be at this address?
Are you in a stable housing situation?
Can we contact you by text?
Can we contact you by email?

If your child is from abroad

Registering with the NHS for the first time in the UK
Please use this date format: DD/MM/YYYY.
Why did your child come to the UK?

Previous Details

Please include postcode.

Details of First Parent/Guardian

Please use date format DD/MM/YYYY.
Any responses we send will go to this email address.

Details of second Parent/Guardian

Please use date format DD/MM/YYYY.

About Your Child

Please specify the ethnic group you consider you belong to:
Does your child have any problems speaking English?
Does your child have any problems reading English?
Does your child need an interpreter when you visit the doctor?
Is your child a main carer (unpaid) for someone who has poor health or disability?

Health

Does your child take regular medication?
Does your child have any long-term illness, health problem or disability?

Immunisations

School or Nursery

Brothers/Sisters/Siblings