Online Registration Form - Gretna Surgery

Please complete the online form below if you wish to register with our practice.

You will need to complete one of these forms for each person you wish to register with our Practice. Those fields marked with an * are required.

1. Personal Details

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

Yes

Gender

Male

Female

Title

Name

Forenames Surname

Previous Surname Optional

(If applicable)

Date of birth

Telephone

Mobile

Address

Street Address Address Line 2 Postcode

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 Optional

NHS Number Optional

The following information can be found on your birth certificate:

Town of birth

Country of birth

Registered District of Birth Optional

(Scotland Only)

Mother's Maiden Name Optional

2. 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

Street Address Address Line 2 Postcode

Name and address of previous GP Practice in UK

Street Address Address Line 2 Postcode

If you are from abroad:

Date you first came to live in the UK Optional

If previously resident in the UK, date of leaving Optional

Your most recent country of residence Optional

If you have served in the British Armed Forces:

Enlistment date Optional

Leaving date Optional

Are you a Reservist?

Yes Optional

No Optional

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

Yes Optional

No Optional

Service Number Optional

Address before enlisting

Street Address Optional Address Line 2 Optional Postcode Optional

3. 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 organdonationscotland.org

4. 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’.

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

5. 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 Optional

Representative’s name Optional

(If applicable)

Relationship to patient Optional

(If applicable)