Durham Road Medical Group Online Registration

Please fill in your details and click Submit when complete.

Please only complete this registration form once. If you have previously submitted this form at
any time please do not do so again unless advised by the Health Centre to do so. If you are unsure
of your registration status, you can contact the practice who will be able to confirm this for you.

Current patients: DO NOT use this form to update your address or other details.

* = Compulsory

* Have you registered with this practice before? Yes   No
* Is this your first registration with a GP Practice in the UK? Yes   No
* Will you be in the area for more than 3 months? Yes   No
* Title:
* Surname (Family name):
* First name(s):
Previous surname:
Mother's maiden name:
* Date of birth:	Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916
NHS Number:
Community Health Index (CHI) Number:
* Gender:	Male   Female   More information...
We appreciate that many people identify as transgender, non binary or intersex. However due to the constraints of the NHS Spine, in order to register you we do need to know the gender you were assigned at birth, or the gender assigned currently on your medical record. If this is something you wish to change or discuss changing, then please after registration make an appointment to discuss taking this further.
* Town of Birth:  * Country of Birth:   Registered district of Birth:
Please select your student accommodation or fill in your new ADDRESS in Edinburgh:
You can check that you live within the practice area by clicking this link.
Student Accommodation:	Select... Arran House Ascham Court Baird House - Pollock Halls Blackfriars Blackwood Crescent Bridge House Buccleuch Place Lane 1-6 Buccleuch Place 7-13 Canal Point Chalmers Chancellor's Court - Pollock Halls Churchill House College Wynd Darroch Court David Horn House Deaconess East Newington Place Edward Salvesen Hall - Mylnes Court Ewing House - Pollock Halls Fleming House Fraser Court Grant House - Pollock Halls Hello Student Hermits Croft Holland Annex - Pollock Halls Holland House - Pollock Halls IQ - Dundee Street IQ - Grove Street John Burnett House - Pollock Halls Kincaids Court Kitchener House Lee House - Pollock Halls Meadow Court Morgan Court New Arthur Place O'Shea North O'Shea South Patrick Geddes Hall - Mylnes Court Philip Henman Hall - Mylnes Court Portsburgh Court Potterow Ratcliffe Terrace Riego Street Robertsons Close Roxburgh Place Salisbury Court South Clerk Street Sugarhouse Close The Old Printworks Turner House - Pollock Halls Vita Student Warrender Park Crescent West Mains Road
Flat/Room:
House/Hall:
* Street Address:
* Town:
* Postcode:
You can check that you live within the practice area by clicking this link.
* Email address:
* Confirm Email address:
* UK Mobile telephone number:
* May we contact you using email?	Yes   No
* May we contact you using SMS text?	Yes   No   More information about texts...
Here at Durham Road Medical Group we are introducing a new text messaging system. This is where you can receive a text message reminding you of upcoming appointments, inviting you in for healthcare reviews (COPD, asthma, diabetes etc.) It can also let you cancel appointments or accept these invitations without having to come in or contact us. If you are happy and would like to receive text messages from Durham Road then please select ‘YES’ above. If you would not like to receive text messages from Durham Road then please select ‘No’ above. Please note; we will only send information that is relevant to the individual and will not send spam. We will also not send any sensitive information such as test results via text message.
* Do you come from ABROAD?  Yes   No
Fill in if you come from abroad * Date you first came to live in the UK: Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 If previously resident in the UK, date of leaving: Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Your most recent country of residence:
LAST ADDRESS in UK when you were registered with a GP Name and address of PREVIOUS GP Practice in UK House: * Street: * Town: * Postcode: * Practice Name: Street: Town: * Postcode:
* Full name: EMERGENCY CONTACT  * Phone no:   * Relationship:
Your OCCUPATION:
Have you served in the British Armed Forces? Yes   No Is this your first registration with a GP since leaving the Armed Forces? Yes   No Service or Personnel No: Address: (before enlisting) Town: Postcode: Enlistment date: Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Leaving date: Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Are you a Reservist? Yes   No
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 to take the time to make your donation decision and record it, go to www.organdonationscotland.org
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.
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/Representative Signature:	Clear
Representative's name (if applicable):
Relationship to patient (if applicable):
Health Questionnaire
* Ethnic origin: Please select... Scottish Other British Irish Gypsy/Traveller Polish Other white ethnic group Any mixed or multiple ethnic groups Pakistani, Pakistani Scottish or Pakistani British Indian, Indian Scottish or Indian British Bangladeshi, Bangladeshi Scottish or Bangladeshi British Chinese, Chinese Scottish or Chinese British Other Asian, Asian Scottish or Asian British African, African Scottish or African British Other African Caribbean, Caribbean Scottish or Caribbean British Black, Black Scottish or Black British Other Caribbean or Black Arab, Arab Scottish or Arab British Other ethnic group Prefer not to answer Do not know your ethnicity Other ethnicity: First language: Please select... English - Abkhazian Afar Afrikaans Akan Albanian American Sign language Amharic Arabic Aragonese Armenian Assamese Australian sign language Avaric Avestan Aymara Azerbaijani Bambara Bamoun Bamun Bashkir Basque Belarusian Bengali Bihari Bislama Bokmal, Norwegian Bosnian Braille British sign language Bulgarian Burmese Cantonese Catalan Central Khmer Chamorro Chechen Chichewa Chinese Church Slavic Chuvash Cornish Corsican Cree Croatian Czech Danish Dari Divehi Dutch Dzongkha English Esperanto Estonian Ethiopian Ewe Faeroese Faroese Farsi Fijian Filipino Finnish Flemish French French Creole Frisian Fulah Gaelic Galician Georgian German Greek Greenlandic Guarani Gujarati Haitian Hakka Hausa Hebrew Herero Hindi Hindko Hiri Motu Hungarian Iba Iban Icelandic Ido Igbo Indonesian Interlingua Interlingue Inuktitut Inupiaq Irish Italian Japanese Javanese Kalaallisut Kannada Kanuri Kashmiri Kazakh Kikuyu Kinyarwanda Kirghiz Komi Kongo Konkani Korean Kuanyama Kurdish Kutchi Lao Latin Latvian Limburgan Lingala Lithuanian Luba-Katanga Luganda Luxembourgish Macedonian Main spoken language NOS Makaton sign language Malagasy Malay Malayalam Maltese Mandarin Manx Maori Marathi Marshallese Moldavian Mongolian Nauru Navajo Ndebele Ndonga Nepali Northern Sami Norwegian Norwegian Nynorsk Occitan Ojibwa Oriya Oromo Ossetian Pali Panjabi Pashto Patois Persian Polish Portuguese Punjabi Pushto Quechua Romanian Romansh Rundi Russian Samoan Sango Sanskrit Sardinian Serbian Serbo-croatian Shona Sichuan Yi Sindhi Sinhala Sinhalese Slovak Slovenian Somali Sorani Kurdish Southern Sotho Spanish Sundanese Swahili Swati Swedish Sylheti Tagalog Tahitian Tajik Tamil Tatar Telugu Tetum Thai Tsonga Tswana Turkish Turkmen Twi Uighur Ukrainian Urdu Uzbek Venda Vietnamese Volapuk Walloon Welsh Western Frisian Wolof Xhosa Yiddish Yoruba Zhuang Zulu Interpreter required? Yes   No
* Height:  cm * Weight:  kg
* Do you SMOKE? Yes   No   Used to smoke
Do you DRINK more than the government recommended amount of alcohol? Yes   No
EXERCISE Healthy exercise usually involves activity that usually lasts for at least 20 minutes, raises the pulse and produces hard breathing. In younger people this might be running, cycling, aerobics or swimming or for older people this may be a brisk walk. How often do you take this type of exercise? Please select... Daily 4 times weekly Once weekly Seldom Cannot exercise
Do you suffer from any ALLERGIES?Yes   No  * Please state any allergies you have: Do you have to carry an adrenaline pen for allergies? Yes   No
Please tick if you are currently receiving treatment for any of the following CONDITIONS:                 ADHD Epilepsy                 Diabetes Heart Disease                 Bipolar Disorder High blood pressure                 Cancer Schizophrenia                 Coeliac disease Thyroid disease                 Asthma Have you had any emergency admissions to hospital in the past year for your asthma? Yes   No Please provide date and more information:                 Please enter Date of Diagnosis, Medication and other relevant Information about your condition:                 Any other significant condition: FAMILY HISTORY - Does any illness run in your family, e.g. diabetes, heart disease, high blood pressure, high cholesterol, cancer, glaucoma? Who was affected and what were their ages when FIRST affected?
Are you on regular, repeat MEDICATION at present?Yes   No  (including the pill and depo-injections) * Please list any regular medicines you use: Please call to book and appointment with the pharmacist at least 2 weeks before your medication runs out .
Have you ever had a SMEAR test?  Yes   No Date: Where: Result:
Do you act as a regular CARER for anyone? Yes  No  DURHAM ROAD MEDICAL GROUP and VOCAL Carers Centre are working in partnership to identify and support carers. What is a carer? Carers are family members or friends who are looking after or supporting someone who is frail, ill ordisabled. Caring roles vary from situation to situation. Carers can be involved in a large number of tasks including assisting with bathing, dressing, giving medication, helping with paying bills and organizing the house among many others. How can VOCAL help? Caring can present many challenges and VOCAL offers free services to support carers when dealing with them. The team at VOCAL can answer your questions, provide practical support to help you access services like respite and home help as well as financial entitlements, provide training and information, a listening ear or counselling. What happens next? If you are a carer fill in the form below or if you have a carer pass this form to them. When VOCAL receives a completed form we will send you an information pack, which includes information about carer’s rights and services to support carers and people with disabilities or in poor health. We will also add you to our mailing list and send you a newsletter three times a year. Durham Road Medical Group will indicate on your records that you have a caring role enabling them to provide you with appropriate health care. Number of years caring: Number of hours caring per week: Information about the person you care for: Relationship to you: Illness/condition: Age: Do you care for more than one person? Yes  No  If yes, please list age and condition of other people that you support: I would like DURHAM ROAD MEDICAL GROUP to record that I am caring on my records? Yes  No  I would like VOCAL to send me an information pack and add me to their mailing list? Yes  No   I would like VOCAL to call me at home to discuss my situation? Yes  No
HOUSEHOLD What best describes your current housing? Please select... Owner occupier Rented - Housing association or Council Rented - Private landlord Homeless or Temporary Accommodation Other Household Composition: Does anyone else live with you? Please enter name(s) and relationship to you:
COMMUNICATION DIFFICULTIES Do you have any trouble, eg speaking/ hearing/ seeing/ reading or writing? Please select... Poor hearing/ Deafness Speech difficulties Poor vision/ blindness Difficulty on the telephone Difficulty reading and/or writing Other
Please read our Privacy Notice.

The information you are submitting will be sent encrypted to the medical practice over the Internet, which still isn't 100% secure.
If you are worried about this you can instead obtain a form from the medical practice that can be filled in and delivered by hand.