About You (Parent or Guardian)
Next of Kin / Name of person(s) with legal parental responsibility
Please state name, relationship to child & if they are registered with us
Private Caring Arrangements
Your Child’s Background Information. Due to government policy, we are obliged to ask you the following:
Looking after a family member/carer
Please let us know if your child is looking after someone who is ill, frail, disabled, has mental health/emotional support needs, or substance misuse.
Your Child’s Medical Background
Please state the condition, year diagnosed and if it is ongoing
Please state the name of medication, dosage & frequency
Please record any significant family history of close relatives with medical problems and confirm which relative e.g. mother, father, brother, sister, grandparent.
Your Child’s Pharmacy Services
Sharing your child’s medical record
Parent/Guardian permission given
Thank you for completing this form
Please see our practice leaflet/website for further information about our team/services.