Application to Register with a General Medical Practitioner - GPR (Scotland) & New Patient Questionnare

Application to Register with a General Medical Practitioner - GPR (Scotland) & New Patient Questionnare

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.

  • 1. Personal Details

    Date of Birth
    For example, 15 3 1984
    Sex (optional)
    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' then ask for form GMSTRF001"

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

  • If you are from abroad

    Date you first came to live in the UK (optional)
    For example, 15 3 1984
    If returning from abroad, date of departure from UK (optional)
    For example, 15 3 1984

  • If you have served in the British Armed Forces

    Enlistment date (optional)
    For example, 15 3 1984
    Are you a reservist? (optional)
    Leaving date (optional)
    For example, 15 3 1984
    Is this your first registration with a GP since leaving the armed forces? (optional)

  • 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.

  • 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

  • Leith Mount Surgery Patient Questionnaire

  • Your Details

    I confirm that I live within the practice boundary (checked on website
    Have you been registered at Leith Mount Surgery Before?

  • Contacting You

    Do you agree that you may be contacted from time to time, via SMS, with practice news, advice about my health and/or appointment

  • Information about you

    Do you need an interpreter?

  • Medical Information

    Have you ever suffered from? (tick as appropriate) (optional)
    Drug Use: - Do you take drugs (optional)
    Have you ever suffered from? (tick as appropriate) (optional)
    Do you have any other mental health issues? (optional)

  • Family History

  • Carers

    Are you an unpaid carer (i.e. you voluntarily provide continuing care for someone who could not manage without your help) ? (optional)

  • Smoking

    Do you smoke?
    If 'No', have you ever smoked?
    Would you like advice on giving up smoking? (optional)

  • Alcohol

  • For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)

  • Child Health & Wellbeing

    In order to help us identify children who may benefit from extra support

    Is your child on the child protection register (optional)
    Has your child previously been on the child protection register (optional)
    Does anyone in your household use non prescribed drugs? (optional)
    Does anyone in your household have a regular prescription for methadone or diazepam? (optional)
    Does anyone in your household drink alcohol to excess? (optional)

  • Females Only

  • Signature

  • 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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Page last reviewed: 15 January 2025
Page created: 09 January 2025