Reception: 6 week baby & postnatal check

The 'six-week check' is part of the NHS Newborn and Infant Physical Examination (NIPE) programme. Along with the newborn examination, it is an essential part of the 'Healthy Child Programme', the Department of Health guideline for promotion of child health. An examination of the infant should take place between 6 to 8 weeks. As well as checking your baby we want to check in with you to make sure you feel well and are recovering properly. Please bring your red book to your appointment.

If you have had twins please complete a form for EACH baby.

We recommend you click here for more information about what happens at your 6 week check: What happens at your 6 week check?

If you were due to have your cervical smear while you were pregnant this can be done >12 weeks post delivery. Book your cervical smear appointment.

Request an implant/copper coil/hormonal coil fitting

Please do not write any clinical queries on this form. Any clinical queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 331401. We will start to process your form by the next working day but it will take up to 5 working days to complete. Please DO NOT call before 5 working days as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

Baby's Information

Babies Full Name:

Babies Date of Birth (DD/MM/YYYY):

Where were they born?

Delivery method:

Feeding method?

Any issues with feeding currently?If no issues please write 'No issues'

Any family history of development dysplasia of the hip?

Mother's Information

Mothers Full Name:

Mothers Date of Birth (DD/MM/YYYY):

What is your plan regarding contraception?

No Contraception

Hormonal patches

Combined contraceptive pill

Progesterone only pill

Condoms only

Diaphragm

Implant/Copper coil/Hormonal coil (To request these click on the link above)

Mothers Height:

Mothers Weight (In kg or stone):

Are you having trouble holding in your pee or wind, or you're soiling yourself with poo?

If yes, please explain further below (if no then move on to the next question):

Are you still having any vaginal discharge?

Smoking Status:

I confirm I am happy to be contacted by the surgery (text or call) on the number provided to arrange a time to visit the surgery

Please note: if you experience a fever (>37.8C) or a persistent cough (>4 hours) do not attend your appointment at the surgery. Instead cancel your appointment and self-isolate for 7 days. Visit out Coronavirus page for more information. https://www.clmp.org.uk/Information-Zone/Coronavirus-Navigation-Hub

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Clarendon Lodge Medical Practice • Clarendon Lodge, 16 Clarendon Street, Leamington Spa, Warwickshire, CV32 5SS.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.