Rinnes Medical Group

Rinnes Medical Group

Mount Street, Dufftown, AB55 4FJ

Telephone: 01340 820888 / Prescriptions 01340 821636

gram.rinnesadmin@nhs.scot

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Rattray’s Lane, Tomintoul, AB37 9HF | Telephone: 01340 820888

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Permanent Registration Form

"*" indicates required fields

Patient details

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

Gender*

Date of Birth*

DD slash MM slash YYYY

Title*

First Name(s)*

Surname*

Current Address and Postcode*

Telephone*

Mobile*

Email Address*

CHI Number

NHS Number

Town of Birth*

Country of Birth*

Registered district of birth

Mother's maiden name

Please help us trace your previous medical records by providing the following information

Address in UK when you were last registered with a GP*

Name and address of previous GP Practice in UK*

Are you from abroad?*

Yes

No

Date you first came to UK

DD slash MM slash YYYY

If previously resident in the UK, date of leaving

Your most recent country of residence

Have you or any immediate family served in the British Armed Forces?*

Yes

No

Service Number

Enlistment date

Leaving date

Are you a Reservist?

Yes

No

If yes, provide your address before enlisting

Is this your first registration with a GP since leaving the armed forces?

Yes

No

Preferred Pharmacy:*

Dufftown Pharmacy

Rothes Pharmacy

Aberlour Pharmacy

Patient's SMS/Text Consent*

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 that you take this time to make your donation decision and record it, go to www.organdonationscotland.org

HOW WE USE 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.

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.

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 / Patient's representative signature

Signature

Representative's name (if applicable)

Relationship to patient (if applicable)

Date

DD slash MM slash YYYY

FOR PRACTICE USE ONLY

Follow this link to access Privacy Policy

I consent to my data being stored according to the Privacy Policy

Follow this link to access Privacy Policy

Comments

This field is for validation purposes and should be left unchanged.

74082

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Leaflets/Information

Rinnes Opening Times

Monday
08:00am to 06:00pm
Tuesday
08:00am to 06:00pm
Wednesday
08:00am to 06:00pm
Thursday
08:00am to 06:00pm
Friday
08:00am to 06:00pm
Saturday
CLOSED
Sunday
CLOSED

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"*" indicates required fields

Name*

First Last

Date of Birth*

Address*

Phone*

Email*

Smoking Status*

How many per day?*

Follow this link to access Privacy Policy

I consent to my data being stored according to the Privacy Policy

Follow this link to access Privacy Policy

Name

This field is for validation purposes and should be left unchanged.

10942

Register as a PERMANENT patient

"*" indicates required fields

Patient details

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

Gender*

Date of Birth*

DD slash MM slash YYYY

Title*

First Name(s)*

Surname*

Current Address and Postcode*

Telephone*

Mobile*

Email Address*

CHI Number

NHS Number

Town of Birth*

Country of Birth*

Registered district of birth

Mother's maiden name

Please help us trace your previous medical records by providing the following information

Address in UK when you were last registered with a GP*

Name and address of previous GP Practice in UK*

Are you from abroad?*

Yes

No

Date you first came to UK

DD slash MM slash YYYY

If previously resident in the UK, date of leaving

Your most recent country of residence

Have you or any immediate family served in the British Armed Forces?*

Yes

No

Service Number

Enlistment date

Leaving date

Are you a Reservist?

Yes

No

If yes, provide your address before enlisting

Is this your first registration with a GP since leaving the armed forces?

Yes

No

Preferred Pharmacy:*

Dufftown Pharmacy

Rothes Pharmacy

Aberlour Pharmacy

Patient's SMS/Text Consent*

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 that you take this time to make your donation decision and record it, go to www.organdonationscotland.org

HOW WE USE 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.

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.

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 / Patient's representative signature

Signature

Representative's name (if applicable)

Relationship to patient (if applicable)

Date

DD slash MM slash YYYY

FOR PRACTICE USE ONLY

Follow this link to access Privacy Policy

I consent to my data being stored according to the Privacy Policy

Follow this link to access Privacy Policy

Name

This field is for validation purposes and should be left unchanged.

83251

Register as a TEMPORARY patient

Full Name:(Required)

Date of Birth:(Required)

Place of Birth:(Required)

Gender:(Required)

Contact Telephone Number:(Required)

Email Address:(Required)

TEMPORARY Address:(Required)

PERMANENT Address:(Required)

Name of Permanent GP Practice:(Required)

Temporary Registration Date:(Required)

Reason for Temporary Registration (PLEASE REFER TO OUR WEBSITE IF YOU REQUIRE MEDICATION)(Required)

Medical Information (Please let us know anything your your medical condition in order for us to better your requirements ie. allergies etc

Follow this link to access Privacy Policy

I consent to my data being stored according to the Privacy Policy

Follow this link to access Privacy Policy

Phone

This field is for validation purposes and should be left unchanged.

7578

Vision Online Patient Services

Patient's First Name(s):(Required)

Patient's Surname:(Required)

Patient's Date of Birth:(Required)

DD slash MM slash YYYY

Patient's Telephone No:(Required)

Patient's Email Address:(Required)

Patient's SMS/Text Consent(Required)

Yes

No

Are you completing this form on behalf of the patient?(Required)

Yes

No

Address (if completing this for a patient):

Your telephone contact number:

Signature(Required)

Follow this link to access Privacy Policy

I consent to my data being stored according to the Privacy Policy

Follow this link to access Privacy Policy

Name

This field is for validation purposes and should be left unchanged.

61224

New Patient Questionnaire

Welcome to Rinnes Medical Group. Please take a few minutes to read and then complete this form before you come to the Practice for your new patient medical appointment with the nurse. PLEASE BRING ALONG A SPECIMEN OF URINE.

Name:

Date of Birth:

Address

Previous GP Name & Address:

Telephone number:

Are you a carer?:

Yes

No

Which ethnic group do you belong to? (Please note, you are not obliged to complete this section)

White

Chinese

Indian

Bangladeshi

Pakistani

Black-African

Black Caribbean

Other - please state below

I do not wish to give this information

Other:

Please list any accidents or operations that you have had in the past

Do you suffer from any of the following?:

Asthma

Diabetes

Heart Disease

Epilepsy

Non-drug Allergies

Any other illness

None of the above

Any other illness:

Please identify what prescribed medication/medication bought over the counter/herbal remedies you take:

Any known allergies/reactions to medicines?:

Yes

No

Please specify:

Do you smoke?:

Yes

No

If Yes, how many per day?:

If you are an ex-smoker, when did you stop smoking?:

Do you drink alcohol?:

Yes

No

If yes, how much?:

Do you exercise regularly?:

Yes

No

If yes, what type of exercise:

Please tick which immunisations you have had:

MMR

Whooping Cough

German Measles

Diptheria

Polio

Hepatitis B

Tetanus

Influenza

TB

Please specify any other immunisations not listed above:

Have your parents or siblings suffered from any of the following?:

Heart Disease

Yes

No

Asthma

Yes

No

Strokes

Yes

No

Diabetes

Yes

No

Epilepsy

Yes

No

Any other illness

Yes

No

If yes, please specify any other illness:

Number of children?:

Number of miscarriages?:

Date of last cervical smear?:

Have you had any breast X-rays?:

FOR GP/NURSE ONLY

BP:

Height (cm):

Weight (kg):

Urine:

Signed:

Date:

Follow this link to access Privacy Policy

I consent to my data being stored according to the Privacy Policy

Follow this link to access Privacy Policy

Phone

This field is for validation purposes and should be left unchanged.

69632

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