New patient registration form (under 16 years) – Linlithgow Group Medical Practice

Do you live inside our practice boundary?(Required)

Look at our Practice boundary map to check. If you cannot access this map, please contact or visit the practice to check before you complete this form. If you don't live within the boundary you will be removed from the practice list.

Yes, I confirm I live inside the practice boundary.

No, I do not live inside the practice boundary.

Please confirm that you will be staying in the area for more than 3 months(Required)

Yes, I will be staying in the area for more than 3 months

No, I will not be staying in the area for more than 3 months

Stop! You may not be able to register with this GP practice

If you live outside our boundary or you are not staying in the area for more than 3 months, please do not complete this Permanent Resident Form. Contact the practice to collect a Temporary Resident Form.

Section 1: Patient registration

1. Personal details

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

Yes

Gender(Required)

Male

Female

Date of birth(Required)

Day

Month

Year

Title(Required)

Surname(Required)

Forenames(Required)

Previous surname(Required)

House/Flat name or number(Required)

Address(Required)

Postcode(Required)

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.

Email address

Telephone number

Mobile number

Is this the patient's mobile number or a relative's mobile number?(Required)

This is the patient's mobile number

This is a relatives / representatives mobile number

No mobile number has been entered

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(Required)

Country of birth(Required)

Registered district of birth

(Scotland only)

Mother’s maiden name

(Scotland only)

2. Help us to trace your previous GP health records by providing the following information

Previous home address in UK when last registered with a GP(Required)

Previous postcode in UK when last registered with a GP(Required)

Name and address of previous GP Practice in UK(Required)

Postcode of previous GP Practice in UK(Required)

Are you from abroad?(Required)

Yes

If you are from abroad:

Date you first came to live in the UK(Required)

If previously resident in the UK, date of leaving(Required)

Your most recent country of residence(Required)

2. 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

3. How we use your 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’.

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

4. 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.

Patient / Patient’s representative signature

Type your name here

Representative’s name (if applicable)

Relationship to patient (if applicable)

Date(Required)

Day

Month

Year

Section 2: About you and your health

What is your ethnic origin?(Required)

White Scottish

White Irish

White English

White Welsh

Polish

Indian

Pakistani

Chinese

Bangadeshi

Black Caribbean

Black African

Black British

Other

Please specify your ethnic origin(Required)

Do you need an interpreter or sign language support?(Required)

Yes

If you do need an interpreter, what language do you speak?(Required)

Please list any medication you take regularly, and the reason for taking these

Have you had any operations or illnesses?

Please list the main details of these

Have you any allergies?

Please list any drugs or chemicals you are allergic to

Immunisation history(Required)

Please give details and dates of all immunisations

Section 3: Next of kin / Emergency contacts

The person named below is my Next of Kin / Emergency Contact and I authorise you to release this information to the emergency services and / or hospital if required.

Next of kin / Emergency contact (1)

Next of kin name (1)(Required)

Next of kin address (1)(Required)

Next of kin telephone number (1)(Required)

Next of kin relationship to patient (1)(Required)

Next of kin / Emergency contact details (2)

Next of kin name (2)(Required)

Next of kin address (2)(Required)

Next of kin telephone number (2)(Required)

Next of kin relationship to patient (2)(Required)

Key information consent

I consent to the sharing of Key Information from my medical records with Out of Hours, ambulance service, NHS 24 & A&E Department in the event of an emergency situation.(Required)

Yes

Section 4: Online services access

I wish to have access to the following online services:

Please tick all that apply

1. Cancelling / viewing appointments

2. Requesting repeat prescriptions

3. Requesting acute prescriptions

I wish to use online services(Required)

Please read each statement carefully and tick before selecting.

1. I have understood the information provided by the practice

2. I will be responsible for the security of the information that I see or download

3. If I choose to share my information with anyone, this is at my own risk

4. I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement

5. If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible

What is your preferred place of collection for your prescriptions?

Linlithgow Group Medical Practice

Dears

Boots

Linlithgow Pharmacy

Section 5: Consent

I consent to the practice contacting me or a parent /guardian via SMS Text Message(Required)

Yes, I consent

No, I do not consent

Not for medical help(Required)

Yes, I understand this form is NOT for urgent medical help

Consent(Required)

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.

I agree to the privacy policy.