New Patient Registration

We welcome anyone to register with us who lives within the practice area - please check with the reception staff for details of the exact boundary, as we unfortunately cannot care for people who are outside this area. Sadly this also includes existing patients who move outside the area - our area is comparatively very large but we have to set limits, especially as we may need to visit you at home.

Registering is simple and involves completing a short form for the Health Authority and a health questionnaire. You will also be required to provide proof of residency (photo ID and a utility bill).

It helps us if you know the details of your existing GP and your NHS number. It can take several weeks for your notes to arrive from your home doctor, so please bring any relevant information with you. You will need to have an appointment with your new GP before you can receive any prescriptions.

We will endeavour to register you with the practitioner of your choice and we will give you an explanation if we are unable to comply.

You can hand in your completed registration forms between 10.30am - 12 noon or 2.00 - 4.00pm, or complete the form online below.

Repeat Medication

If you are on regular (repeat) medication, please supply us with a copy of your re-order slip from your previous practice. This is important because it lists the name, strength and dose of the medication you are taking. Our Practice Pharmacist will process your repeat medication and we aim to have this available for you to order within 4 weeks. If you need your medication before this, please notify reception. The pharmacist may call you to discuss your needs.

On-line Prescription Ordering

We use an on-line ordering system called patient services which will enable you to order your repeat medication online. You will also be able to view any upcoming appointments and also cancel them if they are no longer required. Please complete the registration form provided for this.

Text Reminder Service

Dedridge Medical Group operates a text reminder service. We will send reminders of any appointments you have with Doctors and Nurses in the practice to the mobile phone number you have provided to us.

You will also be able to cancel any appointments you no longer require by simply replying with the word CANCEL. If cancelling in this way, type only the word CANCEL, otherwise it will not be recognised. There may be a rare occasion when you do not receive a reminder, this could be as a result of software updating and unfortunately we cannot avoid this. As this is a reminder service you should not rely on this as a diary for your appointment.

Please be aware that your number will be registered on our system and we will send information to you in this way. If you change mobile numbers, or pass your phone to another person, it is your responsibility to tell us, otherwise, that person may receive the information intended only for you to the mobile number you provided to us.

Younger people over the age of 12 may have reminders sent to their own mobile number if required, but we will ask for a personal number on reaching the age of 15 yrs. For younger children, the mobile number of the parent or guardian will be used as their contact number.

You may withdraw from this service at any time, please notify reception.

PERSONAL DETAILS

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

Will you be in the area for more than 3 months?

Title

Surname

Forenames

Previous Surname

Date of Birth

Address

Postcode

Please provide the names of all people living at this address

Please provide the names (and address) of any children living at a different address

Telephone

Mobile

email address

Gender at Birth

Which gender do you identify as

Occupation

Marital Status

If widowed, when did your spouse die?

The following information can be found on your current medical card:

Community Health Index (CHI) Number

NHS Number

The following information can be found on your birth certificate

Town of Birth

Country of Birth

Registered district of birth (Scotland only)

Mother's maiden name

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 (including postcode)

Name and address of previous GP Practice in UK (including postcode)

Next of Kin (relationship, name and phone number)

Do you have any communication difficulties? (eg deaf or blind)

Do you have any exceptional care needs of any kind?

Are you a carer?

If yes, who do you care for?

Do you have a carer?

If yes, please provide their name and phone number

Do you help or support a relative, friend or neighbour, who due to an illness, disability or age cannot manage on their own? If so, you are a carer. Carers of West Lothian can offer support, information, advice and a listening ear to carers in the West Lothian area. Please ask at reception for a leaflet.

Have you appointed a Power of Attorney?

If yes, please provide their name and phone number

Do you hold Power of Attorney for any patients registered here?

Do you consent to us sharing important information about your healthcare needs with other healthcare professionals for when your GP surgery is closed? please see leaflet about sharing your Key Information Summary (KIS)

If you are from abroad

Date you first came to live in the UK

If previously resident in the UK, date of leaving

Your most recent country of residence

If you have served in the British Armed Forces

Service Number

Enlistment date

Are you a Reservist?

Provide your address before enlisting (including postcode)

Leaving date

Is this your first registration with a GP since Yes No leaving the Armed Forces?

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.

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.

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

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.

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

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.

Medical History (for over 16's only)

Do you have high blood pressure?

Have you ever had a heart attack or suffered from angina?

Have you ever had a stroke or any weakness down one side?

Have any of your close relations (mother, father, brothers or sisters) had any of the following (if yes, what is their relationship to you?):

Heart Disease

Stroke

Diabetes

Epilepsy

Glaucoma

Cancer

High Blood Pressure

Asthma

Other Inherited Condition

Past Illness (for over 16's only)

What illnesses or operations have you had in the past? Please advise what you had and when you had it.

Have you any disability/handicap?

Have you any allergies?

Please list any tablets or medicines you take

When was your last tetanus injection?

What height are you?

What is your approximate current weight?

Females Only

How many pregnancies have you had? Provide numbers for Births, Miscarriages and Terminations

When did you last have a cervical smear test?

Do you use any contraception? If yes, provide type of contraception used

Smoking

Do you smoke?

If yes, do you smoke

If no, have you

Do you use an e-cigarette?

Alcohol

Please indicate your usual average alcohol intake. (1 unit = 1 glass of wine or ½ pint of beer or single measure of spirit)

Weekly consumption:

Maximum daily consumption in the last week:

What is your ethnic origin?

If you have selected any of the other options for ethnicity please provide details here

Interpretation Service

Do you require an interpreter?

If yes, which language

Do you require sign language translation?

Office Use Only

Field for GP's signature for acceptance into the practice

Field for Patients signature (you will sign this when you come in to the surgery after registration)

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Dedridge Medical Group • Nigel Rise, Dedridge, Livingston, EH54 6QQ.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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