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 Medical 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

* 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 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 Blackwood Crescent Bridge House Buccleuch Place Lane 1-6 Buccleuch Place 7-13 Canal Point Chalmers College Wynd Edward Salvesen Hall - Mylnes Court Hello Student IQ - Dundee Street IQ - Grove Street Kincaids Court Meadow Court Patrick Geddes Hall - Mylnes Court Philip Henman Hall - Mylnes Court Portsburgh Court Potterow Riego Street South Clerk Street Vita Student Warrender Park Crescent
Flat/Room:
House/Hall:
* Street Address:
* Town:
* Postcode:
Our Practice Area covers South Central Edinburgh as far as Princes Street to the north, Craigmillar Park to the east, south along Braid Hills Road and west through Inglis Green Road continuing along Gorgie Road.
* 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
Preferred Pharmacy: Please select... Apple   (65 Dairy Road, EH11 2BZ) Boots - Earl Grey Street   (16-20 Earl Grey St, EH3 9BN) Clear   (26a Brougham Place, EH3 9JU) Craiglockhart   (2 Craiglockhart Rd Nth, EH14 1BU) Fountainbridge - Green   (179 Dundee Street, EH11 1BU) Lindsay & Gilmore - Comiston   (18-20 Comiston Road, EH10 5QE) Lindsay & Gilmore - Slateford   (107 Slaterford Road, EH11 1QY) Lloyds - Bruntsfield   (129 Bruntsfield Place, EH10 4EQ) Lloyds - Gorgie   (Sainsbury Superstore, Gorgie Road) Lorimer   (153 Morningside Road, EH10 4AX) Marchmont   (24 Marchmont Road, EH9 1HZ) Omnicare - Tollcross   (48 Home Street, EH3 9NA) Payton & Finlay   (177 Bruntsfield Place, EH10 4DG) Polwarth   (10 Polwarth Gardens, EH11 1LW) Right Medicine - MacKenzie   (45 Forrest Road, EH1 2QP) Right Medicine - Royal Mile   (67 High Street, EH1 1SR) Right Medicine - Kings   (142 Marchmont Road, EH9 1AQ)
* Do you come from ABROAD?  Yes   No
Fill in if you come from abroad (international student) * 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 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 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:
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 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 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... British Irish Scottish Other white, please state Black Caribbean Black African Black, other, non-mixed origin Black British Black West Indian Black Guyana Black North African Black Arab Black Iranian Black - other African country Black East African Asian Black Indo-Caribbean Black Indian sub-continent Black - other Asian Black - other, mixed Indian Pakistani Bangladeshi Chinese Greek Greek Cypriot Turkish Turkish Cypriot Other European, please state Irish traveller Other ethnic group Traveller - gypsy Arab Prefer not to answer Other:
* Do you SMOKE? Yes   No   Used to smoke
Do you DRINK more than the government recommended amount of alcohol? Yes   No
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 Asthma Heart Disease Bipolar Disorder High blood pressure Cancer Schizophrenia Coeliac disease Thyroid disease Diabetes   Other significant condition: We will contact you in the next month to arrange a consultation. If you have not heard from us by the end of the month, please call and ask for a new patient consultation.
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
VACCINATION HISTORY MMR - MUMPS, MEASLES, RUBELLA: Have you had 2 doses of the MMR vaccine in the past? Yes   No / Not sure You may need MMR vaccination: We will contact you in the next month to arrange vaccination. If you have not heard from us by the end of the month, please call and ask for a MMR vaccination appointment   MENINGITIS ACWY: Are you under 25years of age? Yes   No Is this your first time entering university in the UK?  Yes   No Have you had a dose of Meningitis ACWY vaccine? Yes   No / Not sure You may need Meningitis ACWY vaccination: We will contact you in the next month to arrange vaccination. If you have not heard from us by the end of the month, please call and ask for a Meningitis ACWY vaccination appointment.
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.