Copy of - 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. Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register By sending in this form you are agreeing to receive email and/or sms communications from us. We will only use this information to communicate with you about Penicuik Medical Practice and the service we provide.

Last Updated: 22/08/2024

Personal Details

TITLE *

Surname *

First name(s) *

Previous Surname

Date of Birth *

Confirm Date of Birth (this will help the practice to trace your previous medical records) *

Sex

Female

Male

Telephone *

Mobile *

Email *

Home address *

Postcode *

First registration with a GP in the UK? *

Yes No

Will you be in the area for more than 3 months? - If 'no' then ask for a temporary resident form

Yes No

NHS number (can be found on your medical card or on the top right of your birth certificate)

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)

Voluntary Authorisation for Organ or Tissue Donation

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

How we use information

The information you have provided will be used by NHS Scotland 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 exemption certificates and entitlement cards.

NHS National Services Scotland shares information about you within NHS Scotland to assist in the provision and improvement of NHS Services and the health of the public. When we do this, we do it as described by NHS Scotland in the NHS Inform website under the "how the NHS handles you personal health information" section.

NHS Scotland is made up of various organisations such as NHS Health Boards, GP Practices, the Scottish Ambulance Service or NHS National Services Scotland (the common name of the common services agency for the Scottish Health Service) These organisations are individually responsible for your personal health information. In terms of data protection and privacy laws, they are known as "data controllers"

Find out more about NHS Scotland in the link provided above.

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

Allergies and medication

Do you suffer from any alleries? *

Do you take any regular medication? *

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. By sending in this form you are agreeing to receive email and/or sms communications from us. We will only use this information to communicate with you about Penicuik Medical Practice and the service we provide.

Patient's / Patient's representative signature:

PHONE NUMBER OF YOUR NEXT OF KIN *

Name of your Next of Kin *

Date

Representative's Name (if applicable)

Relationship to patient (if applicable)

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

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