Application to Register with a General Medical Practitioner - GPR (Scotland)

Fields marked REQUIRED are compulsory. You should only send this form if you are sure that you are eligible to join this practice. Sending this form will NOT automatically register you with the surgery. Your details will be kept at the surgery and must be signed by you during your first appointment. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register

1. Personal Details

Surname *

First name(s) *

Previous Surname

Date of Birth *

Sex

Female

Male

Telephone *

Mobile *

Email *

Home address *

Postcode *

Is this your first registration with a GP Practice in the UK?

Yes No

Will you be in the area for more than 3 months? - If 'no' then ask for form GMSTRF001"

Yes No

NHS number (can be found on your current medical card) *

Community Health Index - CHI (can be found on your current medical card) *

Town of birth (can be found on your birth certificate) *

Country of birth (can be found on your birth certificate) *

Reg. district of birth (can be found on your birth certificate)

Mother's maiden name (can be found on your birth certificate)

Please help us to trace your medical records by providing the following information:

Address in UK when last registered with a GP

Postcode

Name and address of previous GP practice in UK

Postcode

If you are from abroad

Date you first came to live in the UK

If returning from abroad, date of departure from UK

Your most recent country of residence

If you have served in the British Armed Forces

Enlistment date

Service Number

Are you a reservist?

Yes No

If yes, please provide your address before enlisting

Postcode

Leaving date

Is this your first registration with a GP since leaving the armed forces?

Yes No

Voluntary consent to organ donation

You have a choice about organ or tissue donation after your death. To find out more about why it is important that you take the time to make your donation decision and record it, go to www.organdonationscotland.org

Patient Declaration

I declare that the information I have given on this form is correct and complete. I understand that, if it is not, appropriate action may be taken. To enable NHS National Services Scotland to confirm my eligibility to lawfully register with a GP and for the purposes of prevention, detection, and investigation of crime, relevant information from this form will be disclosed to the NHS Business Services Authority, NHS National Services Scotland, the Home Office, Identity and Passport Service, HM Revenue and Customs, the General Register Office and Local Authorities.

Patient's / Patient's representative signature: (you will need to sign this at the practice)

Date

Representative's Name (if applicable)

Relationship to patient (if applicable)

How we use your information

The information you have provided will be used by the GP Practice to carry out its various functions and services including scheduling appointments, ordering tests, hospital referrals and sending correspondence. Your information, including your name, gender, date of birth and address, will be passed to NHS National Services Scotland where it will be held on the Community Health Index (CHI). This information is used to register you with the GP Practice, transfer your medical records between GP practices in the UK, make payments to GP Practices for medical services provided, and to process and issue medical cards, medical exemption certificates and entitlement cards. NHS National Services Scotland shares information about you within NHSScotland to assist in the provision and improvement of NHS services and the health of the public. When we do this, we make sure that the information which identifies you as a person and your health information are separated or anonymised. Health condition and treatment information which could identify you will not be used for research purposes by the NHS unless you have consented to this. For more information on how NHS National Services Scotland uses your personal information visit http://www.nhsnss.org. If you have any queries or concerns about how your personal information is used by the NHS please ask for the leaflet ‘Confidentiality – it’s your right’, visit the Health Rights Information Scotland website at http://www.hris.org.uk or ask your GP surgery. NHS National Services Scotland is the common name of the Common Services Agency for the Scottish Health Service.

Privacy and security

Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of registration. Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.

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Application to Register with a General Medical Practitioner - GPR (Scotland)

Application to Register with a General Medical Practitioner - GPR (Scotland)

Further Information