Parkshot Medical Health Questionnaire for Newly Registered Child Patients
Parkshot Medical may contact me about all aspects of my child's health and care using electronic messaging
Please indicate ethnicity:
Please Complete your child's immunisation history (Please check all that apply) *
DTaP / IPV / Hib (Pediacel)
1st Dose
2nd Dose
3rd Dose
4/Booster
Pneumococcal (PCV)
Meningitis B
Meningitis C
Hepatitis B
MMR
Rotavirus
BCG
Has your child had any of the following illnesses? (Please check all that apply)
Has your child had any hospital admissions for serious illnesses or accidents?
Due to Child Protection guidelines, children will not be registered without a parent/legal guardian also being registered at the practice.
A birth certificate may be asked for to confirm who has parental responsibility for a child.
Do you consent for another adult (grandparent, au pair) to seek medical advice/treatment for your child?
WE REQUIRE AN UP TO DATE IMMUNISATION HISTORY OF CHILDREN UP TO THE AGE OF 5 UPON REGISTRATION
PLEASE BRING YOUR RED BOOK TO THE SURGERY
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