Child Patient Registration Form These details are for your child: Full Name Please type your full name. Date of Birth Invalid Input NHI (if known) Invalid Input Parent 1's Name Invalid Input Home Phone Invalid Input Mobile Invalid Input Address Invalid Input Parent 2's Name Invalid Input Mobile Invalid Input Home Phone Invalid Input Address Invalid Input Preferred contact email address Invalid email address. Referring doctor Invalid Input GP if different from above Invalid Input Your Pharmacy Invalid Input Who is your medical insurer? Please select...Southern CrossTowerAIASovereignOne PathUnimedINGOther Please tell us how big is your company. Invalid Input Insurance Number Invalid Input Nil medical insurance Please specify your position in the company Does your child have any medication allergies? Yes No Invalid Input eg Penicillin, Sulphas Invalid Input Do skin tests show any reaction to allergies? Yes No Invalid Input Invalid Input Does your child have any other allergies, eg bee stings etc Yes No Invalid Input Invalid Input Has your child had previous ear, nose or throat surgery? Yes No Invalid Input Invalid Input Has your child had any surgery or serious illnesses? Yes No Invalid Input Invalid Input Does your child have any form of bleeding disorder? Yes No Invalid Input eg Do you bruise easily or is there a family history of such problems? Invalid Input Does your child suffer from diabetes, hypertension, heart disease or lung disease? Yes No Invalid Input Invalid Input Is your child currently taking any medicationsor has taken any recently? Yes No Invalid Input eg drops, sprays, medicines, pills, injections etc Invalid Input Send a copy of our report to your GP? Yes No Invalid Input What is the main reason for seeing Dr Brown? Invalid Input If it is tonsillitis or otitis media (glue ear) please submit this form and then fill out the additional questionnaire Yes I have read and understood your Privacy Statement(*) Yes Click here to read the Privacy Statement Please confirm you have read and understood our Privacy Statement Captcha(*) Refresh Invalid Input Prev Next
