New Patient Registration Form

Fields marked "REQUIRED" are mandatory and must be completed. You should only send this form if you are sure that you are eligible to join this practice and are within the practice boundary.

You also need to complete the NEW PATIENT QUESTIONNAIRE so that your registration request is complete.

Last Updated: 01/03/2023

Patients Details

Title

Surname *

First name(s) *

Previous Surname

Birth Town *

Birth Country *

Date of Birth *

NHS number

Community Index Number (CHI)

Sex

Male

Female

Address *

Postcode *

Telephone *

Please help us trace your previous medical records by providing the following

Your previous address in UK

Name and address of previous GP while at previous address

If you are from abroad

Your first UK address where registered with a GP

Your most recent country of residence

If previously resident in UK, date of leaving

Date you first came to live in UK

If you are returning from the armed forces

Address before enlisting

Leaving date

Are you a Reservist?

Yes No

Service/Personnel No.

Enlistment date

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 eligibiity to lawfully register with a GP and for the purposes of prevention, dectection 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.

Signature

Signature of patient

Signature on behalf of patient

Signed

Date

NOW FILL OUT THE NEW PATIENT QUESTIONNAIRE

Fill in the NEW PATIENT QUESTIONNAIRE so that your registration request is fully completed. Otherwise, your application cannot be processed.

For Practice Use

GP Reference Number

GP Name

Practice Code

For official use only

Input by

Checked by

Date

Practice Stamp

Voluntary authorisation for organ or tissue donation

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

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New Patient Registration Form

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