Registration Form

Registration Form

  • 1. PERSONAL DETAILS (ALL FIELDS MARKED * ARE MANDATORY AND MUST BE COMPLETED AS FULLY AS POSSIBLE

  • Date Format: DD slash MM slash YYYY
  • Community Health Index (CHI) NumberNHS Number 
  • Town of birthCountry of birthRegistered 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 but will be held on the GP's Practice's System
  • 2. HELP US TO TRACE YOUR PREVIOUS HEALTH RECORDS BY PROVIDING THE FOLLOWING INFORMATION

  • If you are from abroad:

  • Date Format: DD slash MM slash YYYY
  • Date Format: DD slash MM slash YYYY
  • If you have served in the British Armed Forces:

  • Date Format: DD slash MM slash YYYY
  • Date Format: DD slash MM slash YYYY
  • 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
  • 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.
  • Date Format: MM slash DD slash YYYY
  • 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.
  • Date Format: DD slash MM slash YYYY

Opening Hours

Mon: 8.20am – 5.30pm
Tues: 8.20am – 5.30pm
Wed: 8.20am – 5.30pm
Thurs: 8.20am – 5.30pm
Fri: 8.20am – 5.30pm
Sat: CLOSED
Sun: CLOSED
Please note: The practice is closed from 1.00pm – 1.45pm Every Wednesday for staff training.

Out of Hours

Out of hours care is provided by NHS 24

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Please note this is for urgent and emergency problems only.

We offer early and late surgeries during the week please ask the receptionist for appointment availability

Contact

Call: 01292 264 260
Fax: 01292 292 160

Address

Fullarton Medical Practice
40 Dalblair Road
Ayr, KA7 1UL