Amendment to Child’s details

I wish to advise you that my child born on *

Please use format day/month/year e.g. 12/05/2019

Was previously known as:

Previous first name(s) *

Previous last name *

Is now known as:

First name(s) *

Last name *

Email *

Phone Number *

Currently resides at:

My child is currently registered with Dr

I confirm

There is a decree absolute (divorce) in respect of the marriage of the parents of this child.

There is NOT a decree absolute (divorce) in respect of the marriage of the parents of this child.

NOTE: If the parents are divorced, both signatures are required.

I confirm

There is an adoption order in respect of this child.

There is NOT an adoption order in respect of this child.

Date of adoption

Please upload the adoption certificate

Maximum file size: 10MB

We accept pdf, jpeg, gif, tif, and png up to 10MB

I confirm

There is a care order in respect of this child.

There is NOT a care order in respect of this child.

Please upload a copy of the care order

Maximum file size: 10MB

We accept pdf, jpeg, gif, tif, and png up to 10MB

I confirm

My child’s name has NOT been changed at the Registrar General’s Office

My child’s name has been changed at the Registrar General’s Office

Please upload a copy of the amended Birth certificate

Maximum file size: 10MB

We accept pdf, jpeg, gif, tif, and png up to 10MB

Please note:
If at a future date this name change is challenged by the other parent, then the Medical Card will be reverted back to the original name, as shown on the child’s Birth Certificate. Any dispute regarding a child’s name must be settled by the courts.

I confirm

I have parental responsibility of this child at present and want a medical card in their new details.

Signature

I have read and understand the above and declare that the information given on this form is true.

Signature of Parent/Guardian

Clear

Please type your name to indicate your signature

Signature of 2nd Parent/Guardian

Clear

Please type your name to indicate your signature

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

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Amendment to Child’s details

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