Children (8 weeks - 15 years old) - New Patient Registration Form & Questionnaire

Thank you for choosing to register with Adelaide Medical Centre. To ensure your child's registration can be fully completed and that their medical record is kept up-to-date, please complete this form as accurately as possible. Do ensure that you have your child's immunisation history available when completing the form.

Last Updated: 19/05/2022

Child's Personal Details

Child's Ethnicity

Parent / Guardian (s) Details

Previous GP

Next of Kin

Contacting You

Please note that Proxy Online Access, to some aspects of the child's medical record can be requested for children under the age of 12. Further information and application can be found on our website.


Child's Medical History

Child's Immunisation History

It is important that we have an up-to-date record of your child's vaccinations to ensure your child is fully immunised in accordance with the UK Immunisation Schedule

Immunisations of Children Aged 12 -15 Years old

Please move to the next section if not applicable

Family Medical History

Additional General Details

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