FPG Client Registration Form

Client Registration

CR1
Date*

DayMonthYear
Date
To register at our practice and access our services please complete this registration form. The information you provide will be encrypted and sent to our Case Management Team.

If you are a parent and registering your child to receive services from the practice, you will need to complete this form as the (Client and Child). If you are over 18 years of age and receiving services for yourself, please complete this form as (Client).
I am registering as a:*

Client (over 18)Client and Child
Your Details

The individual completing the form should provide their details here. For those registering a child or young person their details should be provided on the next page
Title
First Name
Middle Name
Surname
Date of Birth

DayMonthYear
Current Age*
I identify my gender as

MaleFemaleGender-BinaryTransgenderTranssexual
Address

Street Address

Street Address Line 2

CityCounty

Post CodeCountry
Mobile Number
Home Number
Personal Email

Confirmation Emailexample@example.com
Work Email

Confirmation Emailexample@example.com

Medical

We will not contact your GP, or anyone else for that matter without your prior consent, unless during the course of any therapy or assessment a concern is raised for your immediate welfare. To find out more about our confidentiality agreement please read our terms and conditions.

Adults registering children, please provide the child or young person’s GP
Doctors Name
Surgery or Practice Name
Phone Number

Area CodePhone Number
City or Town
Please let us know if any of the following apply

Mobility IssuesLearning Disability or Learning DifficultyOther
Any other significant condition or illness

In case of emergency

Hopefully we will never need to use this but in case of an emergency please provide the contact details for at least one other person.
First Name*
Surname*
Home Number
Mobile Number*
Relationship*

Security and Email

We use an encrypted email system to send consultation letters, reports and assessment results so can you recieve them as quickly as possible. If you would like to take advantage of this we need you to nominate a safe, secure email address that you give consent for us to use. For further information you can view our security and privacy policy online.
Do you consent for us to send confidential information such as reports, assessment results or letters by email (encrypted)*

NoYes
Secure E-mail

Confirmation Emailexample@example.com
Password
We may ask for this to easily identify you or to further secure sensitive documents

Consent to share

If you would like us to speak to a nominated person on your behalf regarding your treatment and/or you consent for us to send confidential information regarding your services to a third party, please complete the following section.

If you would like to register additional persons please use our standard discloure form which can be found on our website.
I give consent for the Family Practice Group and its Associates to contact and share information about me and the services I am being provided with to a nominated third party*

No I do not give consentYes I do give consent
First Name
Surname
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Password
A password we can easily identify you
Relationship
How is this person related to you?
Phone Number

Area CodePhone Number
E-mail
example@example.com

Contact Preferences

Please indicate how you would prefer us to contact you
Please contact me by

MobileHome TelephonePostEmail
If you are unavailable, should we leave messages on either the numbers above? Please tick to confirm it is okay to leave messages for you on your:

Mobile NumberHome Number
When booking an appointment with the Family Practice Group you will automatically receive a confirmation email from us confirming the date and time of your appointment. If you would prefer not to receive these emails please indicate this to us by ticking the box below.

Please do not send appointment confirmation emails