New Patient Registration

Personal Details

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

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

If ‘No’, please contact the practice

Date of birth

Title

Surname

Previous surname

Forenames

Calling name

Sex

Marital Status

Ethnic Origin

Postcode

House Name or Number / Flat No

Street

Town

Home Telephone Number#

Work Telephone Number

Mobile #

Email address #

# the data supplied in these fields will not be input to, or updated in, the Community Health Index (CHI), but will be held on the GP Practice’s system.

The following information can be found on your current medical card:

Community Health Index (CHI) number

NHS number

The following information can be found on your birth certificate:

Town of birth

Country of birth

Registered district of birth (Scotland only)

Mother’s maiden name

HELP US TO TRACE YOUR PREVIOUS GP HEALTH RECORDS BY PROVIDING THE FOLLOWING INFORMATION

Address in UK when you were last registered with a GP (If never had a GP in UK then type 1st register)

Postcode (If never had a GP in UK then type 1st register)

Name and address of previous GP Practice in UK (If never had a GP in UK then type 1st register)

Postcode (If never had a GP in UK then type 1st register)

If you are from abroad:

Date you first came to live in the UK

If previously resident in the UK, date of leaving

Your most recent country of residence

If you have served in the British Armed Forces:

Enlistment date

Service Number

Are you a Reservist?

Your address before enlisting

Postcode

Leaving date

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

VOLUNTARY AUTHORISATION FOR ORGAN OR TISSUE 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

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 NHSScotland 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 your 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’.

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, the minimum necessary information from this form could be disclosed to relevant authorities

I understand that more comprehensive information about how NHS Scotland handles my data is available from NHS Inform.

This information can be provided in other languages and formats on request. The NHS Inform helpline provides an interpreting service

If you are completing this form on behalf of someone else please provide your name

Relationship to patient (if applicable)

For Practice Use Only

GP reference number

GP name

Practice code

Identification seen – do not take or retain photocopies

Please initial each relevant box (it is recommended that at least one form of the identification is seen to positively identify the applicant although it is not mandatory to provide identification to register)

Birth cert

Student ID card

Driving licence

Passport or HC2 cert

Home Office app reg card

Other / None

Other

I accept this patient onto the practice list and declare that, to the best of my knowledge, this information is correct. I acknowledge that the details may be authenticated from appropriate records, and that payments generated from this patient registration will be subject to Payment Verification.

Authorised Practice signature

Date

For Official Use Only

Input by

Checked by

Date

Practice Stamp

New Patient Health Questions

New patients will also need to complete the following health questions

Phone number where you can most easily be contacted

Mobile

Can we send you text reminders

Occupation

Student course

Have you been a patient of this practice before

Allergies

Are you allergic to any medicine/drugs? Or to anything else

If yes, please provide details

Regular / Repeat Medication

We have a repeat prescription service and you can order your prescription in person, by telephone (0141-211 6220)or by e-mail via the Practice website. Please arrange an appointment to see a doctor before your first prescription is due in order to confirm your medication requirements and to enter them on computer. This includes the oral contraceptive pill.

Please specify current medication below

Life Style

Smoking status

Want To Stop Smoking? If you are a smoker and want help to stop we CAN help you. Get in touch with Smoking Cessation Team on 2322110 or contact your local community pharmacy. If you prefer to see a GP or nurse just make an appointment.

Alcohol Screening

½ Pint of beer, 1 glass of wine, 1 single spirit = 1 Unit

Please take time to answer the following questions regarding your alcohol consumption

How often do you have eight (six if you are a women) or more drinks in one occasions?

How often during last year you have failed to do what was normally expected of you because of drink?

In the last year has a relative or friend or a doctor or other health worker been concerned about your drinking or suggested you cut down?

How often during last year have you been unable to remember what happened the night before because you had drink?

Female Patients Only

Date of last cervical smear (Pap test)

Result of the Smear

Where did you have your last smear?

For women aged 50 to 65 only

Date of last mammogram (breast x ray)

Record of Form Submission

We will put a copy of this form in the patients records

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 Buckingham Terrace Medical Practice • 31 Buckingham Terrace, Glasgow, G12 8ED.

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.

Key Information

New Patient Registration

Privacy Protection