Application to Register with a General Medical Practitioner

Personal Details

Sex

Sex Female Male

First registration with a GP in the UK?

First registration with a GP in the UK? Yes No

Will you be in the area for more than 3 months?

Will you be in the area for more than 3 months? Yes No

If 'no' then ask for form GMSTRF001"

Date of Birth

DD	MM	YYYY

Home Address

Surname

First Name(s)

Previous Surname

Postcode

Telephone

Mobile

The following information can be found on your current medical card

NHS No.

Community Health Index (CHI)

The following information can be found on your birth certificate

Town of birth

Country of birth

Reg. district of birth

Mother's maiden name

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

Address in UK when last registered with a GP		Name and address of previous GP practice in UK

Postcode		Postcode

If you are from abroad

Date you first came to live in the UK

DD	MM	YYYY

If returning from abroad, date of departure from UK

DD	MM	YYYY

Your most recent country of residence

If you have served in the British Armed Forces

Enlistment date

DD	MM	YYYY

Service Number

Are you a reservist?

Yes No

If yes, please provide your address before enlisting

Postcode

Leaving date

DD	MM	YYYY

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

Yes No

Voluntary Authorisation for Organ or Tissue Donation

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

Organ donation Any Organ Kidneys Liver Lungs Heart Corneas Pancreas

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.

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)

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.

About This Form

Fields marked with a red asterisk 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