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Elm House Surgery 379 Croydon Road, Beckenham, Kent, BR3 3FD

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NEWBORN BABIES – Up To 8 Weeks Old – Registration Form

NEWBORN BABIES – Up To 8 Weeks Old – Registration Form

To register your child with the practice you will need to complete the below registration form

Please provide us with your child’s NHS number or Red Book to help with this registration.

Upload your Child's Red Book Optional

Drop files here or

Max. file size: 50 MB.

NHS number

If you have an NHS number you must provide this.

Baby's Details

Name

First Last

Gender

Male

Female

Baby’s Date of Birth

Day

Month

Year

Place of Birth/ Name of Hospital

Baby's Address

Street Address Address Line 2 City Postcode

Main spoken language

Ethnicity

For equal opportunity monitoring

Mother’s Name

First Last

Mother’s Date of Birth

Day

Month

Year

Was baby premature?

Yes

No

By how many weeks?

Mother’s Contact Number

Mother’s Email Address

Enter Email Confirm Email

By providing your email address and mobile phone number you consent to us contacting via these methods. If you do not want to be contacted in this way please tick the relevant box below.

Please do not contact me via

Email Optional

Mobile Phone Optional

Baby’s Other Next of Kin Name

First Last

Relationship (e.g. Biological father or other guardian)

Next of Kin Telephone Number

Interpreter Required?

Yes

No

Please note that this practice is signed up to the Summary Card Record (SCR) system and submits data to the NHS care data scheme. If you wish to opt out please ask reception for details on how to opt out. Please see our website for further details.

Family History

Please select if there is any history of the following conditions found in your family.

Conditions

Asthma

Diabetes

Stroke

Breast Cancer

Angina or Heart Attack in a relative aged over 60

Angina or Heart Attack in a relative aged under 60

None of the above

Please state the family member (e.g. mother, father, sister, brother) in which the condition is for

Non-urgent advice: Once your child is registered with the practice, you will also need to set them up as a dependant on your online Anima account

Set up an Anima account

Follow the instructions on our Home Page on how to set up an Anima account.

Please ring Reception if you are experiencing any difficulties with setting up your online Anima account.

Tel. 020 8650 0173

Elm House Surgery is part of the Beckenham PCN

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