Under 16s New Patient Registration

Name of adult registering the child: *

Relationship to child: *

Parent/Guardian's Email Address: *

Parent/Guardian Telephone Number: *

Mobile number for text message reminders.

Parent/Guardian's Full Address inc postcode: *

How would you like us to contact you about your child? *

Letter

Email

Text

Phone

Who has legal parental responsibility? *

Mother

Father

Both

Other

Mother's full name: *

Mother's NHS number:

Is mother registered at this surgery? *

Yes

No

Does mother reside with the child? *

Yes

No

Father's full name: *

Father's NHS number:

Is father registered at this surgery? *

Yes

No

Does father reside with the child? *

Yes

No

Full Name: *

Relationship to child: *

Are you registered at this surgery? *

Yes

No

Is address the same as the child's? *

Yes

No

Address including Postcode: *

Telephone: 020 7602 3797 Out of hours: 111

Address: Sterndale Surgery, 1-13 Milson Road, London, W14 0LJ

Under 16s New Patient Registration

Patient's Details

About You (Parent/Guardian)

Carers Information

Ethnic Origin

Medical Records

If you are from abroad

New Patients

Back to New Patients

Contact the Practice

Policies

Services

Tell us whether you accept cookies

Telephone: 020 7602 3797 Out of hours: 111 Address: Sterndale Surgery, 1-13 Milson Road, London, W14 0LJ