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New Patient Minor Registration (Confidential)

Page 1 of 3

  1. Title* Please select your title
  2. Full Name*
  3. Date of Birth* Select your date of birth
  4. Current Age*
  5. Gender*
    Gender
  6. Full Address* Enter your full address
  7. Postcode* Please enter your postcode
  8. Landline Telephone Please enter your landline number
  9. Mobile* Please enter mobile number
  10. Email* Please enter your email address
  11. Where did you hear about us?
  1. Previous Medical History
  2. Are you currently being treated for any ongoing medical problems?* Please select an option
    Are you currently being treated for any ongoing medical problems?
  3. If Yes, which ones Invalid Input
  4. Are you currently taking any regular medication?* Please select an option
    Are you currently taking any regular medication?
  5. If Yes, which Invalid Input
  6. Are you allergic to any medicines?* Please select an option
    Are you allergic to any medicines?
  7. If Yes, which ones Invalid Input
  8. GP Details
  9. The name of your GP Please enter your GP name
  10. GP Address Enter your full address
  11. Telephone Please enter your landline number
  12. Next of Kin
  13. Name Please enter your next of kin name
  14. Relationship to you Enter your relationship with this person
  15. Address Enter your full address
  16. Telephone Enter this persons contact number
  1. If you have any tests conducted at Edgbaston Private Medical Practice how would you like to be informed of the results? Invalid Input
    If you have any tests conducted at Edgbaston Private Medical Practice how would you like to be informed of the results?
  2. Do you give permission for Edgbaston Private Medical Practice to write to your GP about your attendance.* Please select an option
    Do you give permission for Edgbaston Private Medical Practice to write to your GP about your attendance.
  3. Do you give permission for Independent Body authorised by ourselves to contact you to assess our level of service.* Please select an option
    Do you give permission for Independent Body authorised by ourselves to contact you to assess our level of service.
  4. Do you give permission for the Edgbaston Private Medical Practice to send details of up to date services via email.* Please select an option
    Do you give permission for the Edgbaston Private Medical Practice to send details of up to date services via email.
  5. The information I have given is to the best of my knowledge, correct. I have not knowingly withheld any relevant information medical or surgical information.*
    The information I have given is to the best of my knowledge, correct. I have not knowingly withheld any relevant information medical or surgical information.
    6. Please check the form and agree to the disclaimer

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Edgbaston Private Medical Practice is a trading name of Lister Medical Group Ltd, Registered Office: 44 George Road, Birmingham, B15 1PL, UK Company Reg No.: 09594751

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