Fillable Coldside Medical Practice New Patient Registration Form (London Institute of Management and Technology)

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Coldside Medical Practice New Patient Registration Form (London Institute of Management and Technology)

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The Coldside Medical Practice New Patient Registration Form (London Institute of Management and Technology) form is 2 pages long and contains:

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  • 14 check-boxes
  • 81 other fields

Country of origin: UK
File type: PDF

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GMSGPR001 v5 (04-2019)
YYYY
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1. PERSONAL DETAILS (ALL FIELDS MARKED * ARE MANDATORY AND MUST BE COMPLETED AS FULLY AS POSSIBLE)
Forenames*
Surname*
Address*
-
Male*
Female*
Yes
No
Is this your first registration
with a GP Practice in the UK?*
Will you be in the area for
more than 3 months?*
Yes
No
Previous Surname*
Postcode*
email address #
Mobile #
Telephone #
Community Health Index (CHI) Number*
NHS Number*
The following information can be found on your current medical card:
Town of Birth*
Country of Birth*
The following information can be found on your birth certificate:
Registered district of birth
(Scotland only)
Mother's maiden name
# 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
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*
Postcode*
Name and address of previous GP Practice in UK*
Postcode*
If you are from abroad:
YYYY
MM
DD
-
-
Date you first came to live in the UK*
If previously resident in the UK, date of leaving*
YYYY
MM
DD
-
-
Your most recent country of residence
If you have served in the British Armed Forces:
Yes
No
Is this your first registration with a GP since
leaving the Armed Forces?*
If yes, please provide
your address before
enlisting*
Postcode*
YYYY
MM
DD
-
-
Enlistment date*
YYYY
MM
DD
-
-
Leaving date*
3. VOLUNTARY AUTHORISATION FOR ORGAN OR TISSUE DONATION
I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death.
Please tick the boxes that apply. Your consent to organ donation will be shared with NHS Blood and Transplant together with the information you
have provided in Section 1 including your name, gender, date of birth address and CHI number. For more information on being an organ donor or
privacy, please ask for the leaflet on joining the NHS Organ Donor Register or visit www.organdonationscotland.org
Any of my organs and tissue
Or my
Kidneys
Eyes
Heart
Lungs
Liver
Pancreas
Small bowel
Tissue
Patient signature
YYYY
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-
-
APPLICATION TO REGISTER PERMANENTLY WITH A GENERAL MEDICAL PRACTICE
(If 'No', please complete a temporary resident form)
Title*
Service Number
Date of Birth*
Date
Yes
No
Are you a Reservist?*
Notes on tissue - heart valves and corneas come under the 'heart' and 'eyes' boxes respectively so the 'tissue' box covers donating other types of
tissue, such as your tendons.
GMSGPR001 v5 (04-2019)
Practice Stamp
4. 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.
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
YYYY
MM
DD
-
-
Representative's name (if applicable)
Relationship to patient (if applicable)
6. FOR PRACTICE USE
GP reference number
-
GP name
Practice code
-
Mileage (No.) Road
Water
Footpath
Identification seen - do not take or retain photocopies
Please initial each relevant box (it is recommended that at least one form of 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
- specify
Receptionist
initials
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
YYYY
MM
DD
-
-
7. OFFICIAL USE ONLY
Input by
Checked by
YYYY
MM
DD
-
-
Date
Date
Date
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Coldside Medical Practice New Patient Registration Form (London Institute of Management and Technology)

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Completed 23 July 2021

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