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Name your child is known by
Date of Birth (or expected date of delivery)
Religion (if any)
Does your child have any allergies?
Please give details of your child's allergies
Does your child have any medical conditions?
Please give details of your child's medical conditions including any prescribed medication
Does your child have any learning difficulties or disabilities?
Please give brief details of your child's learning difficulties and/or disabilitites
If known, please select as appropriate:
Referral to Speech & Language
Referral to Portage
Education Health & Care plan
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