Choice Healthcare Services

Children's Registration Form

Fields marked with an * are required.

Enquirer Details

Title	First Name	Surname	Relationship to child

Child Details
Male	Female	Date of Birth
First Name		Surname
Contact Details

Home Tel: *

Work Tel: *

Mobile: *

Email: *

Address: *

Town/City: *

County: *

Postcode: *

Individual Child health Questionnaire

Why have you chosen the single vaccine option

Other vaccinations your child may have had:
Please give details of other vaccinations your child may have already had:

Dip/Tet (Diptheria/Tetanus)		HIB Polio	BCG
Meningitis C		Whooping Cough/Pertissus	Pneumococcal

Other? (please detail)
Other Information
Please detail why you have chosen to undertake your child's course of Single Vaccinations at ChoiceHealthcare:

Your child's general health:
Has your child had any of the following:
Severe reaction(apart from the reaction at the site of injection) to previous injections?*			YesNo
If 'Yes' please give details of the reaction, whether a doctor was consulted and what was done

Allergy to any antibiotic? *			YesNo
If 'Yes' then please specify the name of the antibiotic(s), when and what it was given for, what happened and whether it has been given again since

Allergy to eggs? *			YesNo
If 'Yes' when was this and please give details of the reaction and whether the child has had eggs since without a problem?

Impaired or reduced immunity? *			YesNo
If 'Yes' please give details including any tests and the advice you received about this:

A history of febrile convulsions, or of cerebral(brain) injury? *			YesNo
If 'Yes' please give details

Is your child currently taking any medication? *			YesNo
If 'Yes' please give details:

Do you have any relevant questions?

MMR
Has your child already had the combined MMR? *			YesNo
Did your child have a reaction to the MMR *			YesNo
What type of reaction did your child have

MMR Single Vaccinations

Single measles

Date

Single rubella

Date

Single mumps

Date

Consent and Disclaimer

I give consent for my child to undertake the course of single vaccinations for Measles, Rubella and Mumps at a Choice Healthcare Private General Practice Clinic.

I understand it is advisable for my child to receive three booster injections at a later time to ensure continued immunity into the teenage years

I understand that the vaccines used are on a 'named patient basis' as they do not have a license for single use in the United Kingdom and that they are to be administered by Choice Healthcare to my child.

Please tick if you agree *

Name & Address of my child's GP

Dr: *

Address: *

Postcode: *

You will receive confirmation by email within 48 hours.
If you experience any difficulties booking online please call 0870 770 8545

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Choice Healthcare Services

Children's Registration Form

Individual Child health Questionnaire

Other vaccinations your child may have had:

Other Information

Your child's general health:

MMR

MMR Single Vaccinations

Consent and Disclaimer