New Patient Questionnaire (Child)

WELCOME TO THE ATLANTIC MEDICAL GROUP

Please help us by answering the following questions to update your baby’s / child’s medical records.

Last Updated: 02/03/2023

PATIENT CONTACT DETAILS

Name *

Date of Birth *

Address *

Postcode *

Home Number of main carer *

Mobile Number of main carer *

Work Number of main carer

Email Address of main carer *

NEXT OF KIN

Next of Kin (Name & Relation) *

Contact no for next of Kin *

Address for Next of Kin: *

Next of Kin (Name & Relation)

Contact no for next of Kin

Address for Next of Kin:

Name(s) of legal guardian(s) *

Contact no(s) for legal guardian(s) *

Nominated Pharmacy

Your Nominated Pharmacy *

FAMILY HISTORY

Please state any serious illness, in particular cancer, heart disease, stroke, high blood pressure, diabetes or any inherited disease. Please state your relationship to the individual and in the case of cancer, the type of cancer. *

CONTACTING YOU

Do you agree that you may be contacted from time to time, via email and/or SMS, with practice news, advice about my health and/or appointment reminders. *

Yes No

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New Patient Questionnaire (Child)

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