Fountain Medical Centre

New Patient Registration: Child 5 – 17 years old

FMC Register (GSM1): Child 5 – 17 years old
Title:
Sex:
Address *
Address
Postcode
City
Country
Would you like to receive SMS reminders for your child’s appointments?

Please help us trace your previous medical records by providing the following information:

Your previous address in the UK
Your previous address in the UK
Postcode
City
Country
Address of previous doctor
Address of previous doctor
Postcode
City
Country

If you are from abroad:

Your first address where registered with a GP
Your first address where registered with a GP
Postcode
City
Country

Electronic Prescribing

If you need your doctor to dispense medicines and appliances * :

* Not all doctors are authorised to dispense medicines.

Next of Kin / Emergency Contact

Address:
Address:
Postcode
City
Country
Are you cared for?

Health Details

Please list and date if possible any serious you have or have had in the past

Family History

Have your parents or siblings ever had any of the following
Are you exposed to smoke?