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Yorkleigh Surgery NHS GP Surgery in Cheltenham

New patient registration (child)

New Patient Registration Form – Child

Your Child’s Details

Child’s First Name: *

Child’s Surname: *

Date of Birth: *

Please use the format: DD/MM/YYYY

Home Telephone:

Name of Birth Mother:

Address Including Postcode: *

How would you best describe your gender? *

Is your gender identity the same as the sex you were assigned at birth? *

Yes

We are asking for this information to match your GP record.

Parent or Guardian Details

Your Name: *

Relationship to Child:

Preferred Telephone Number: *

Address Including Postcode: *

Work Telephone:

Date of Birth: *

Please use the format: DD/MM/YYYY

Email: *

Please use the format: email@example.com

I consent to be contacted by SMS on this number.

I consent to be contacted by Email at this address.

It is your responsibility to keep us updated with any changes to your telephone number, email & postal address.

Other Details

Name of Previous GP:

Address of Previous GP:

Country of Birth:

Name of School:

Ethnicity:

White (UK)

White (Irish)

White (Other)

Black Caribbean

Black African

Black (Other)

Bangladeshi

Indian

Pakistani

Arabic

Chinese

Other

Please specify:

Religion:

C of E

Catholic

Other Christian

Buddhist

Hindu

Muslim

Sikh

Jewish

Jehovah’s Witness

No Religion

Other

Please specify:

Housing:

Own Home

Rented Home

Shared House

Sheltered House

Asylum Seeker

Refugee

Are you an overseas visitor?

Yes

Do you have a European Health Insurance Card?

Yes

Please provide this along with your ID and other documents.

Armed Forces:

Family Member

Military Veteran

If you are human, leave this field blank.

93 St George’s Road
Cheltenham
Gloucestershire
GL50 3ED

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01242 519049

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