GMS1w Patient Registration Form – SA1 Medical Centre and St David's Surgery

GMS1w Patient Registration Form - standard (2)

Patient's details [Manylion y claf]

Title(Required)

Mr [Mr]

Mrs [Mrs]

Ms [Ms]

Miss [Mis]

Mx [Mx]

Other

Please add your title

Surname [Cyfenw](Required)

First names [Enwau cyntaf](Required)

Previous surnames [Cyfenw(au) blaenorol]

Known name [Adnabyddir fel]

Mothers Maiden Name [Enw’ch mam cyn priodi]

Sex(Required)

Male [Gwryw]

Female [Benyw]

Date of birth [Dyddiad geni](Required)

Day

Month

Year

NHS Number [Rhif GIG]

Please enter your NHS number here as this is required to process your application.

Town and country of birth [Tref a gwlad eich geni](Required)

Current address [Cyfeiriad presennol](Required)

Postcode [Cod Post](Required)

Telephone number [Rhif ffôn](Required)

Your email address(Required)

Enter Email Confirm Email

Please help us trace your previous medical records by providing the following information [Helpwch ni i olrhain eich cofnodion meddygol blaenorol drwy ddarparu’r wybodaeth ganlynol]

Your previous address in UK, whilst registered with a GP surgery [Eich cyfeiriad blaenorol yn y DU, pan oeddech wedi’ch cofrestru gyda meddygfa meddyg teulu]

Name of previous GP practice while at that address[Enw’ch meddyg blaenorol pan oeddech yn y cyfeiriad hwnnw]

Please enter your previous GP in the UK as this is required to complete your registration.

Address of previous doctor [Cyfeiriad eich meddyg blaenorol]

Please enter your previous GP in the UK as this is required to complete your registration.

Postcode [Cod Post]

If you are from abroad [Os ydych o dramor]

Your first UK address where registered with a GP [Eich cyfeiriad cyntaf yn y DU lle roeddech wedi cofrestru gyda meddyg teulu]

Have you ever registered with a NHS GP in the UK? [Ydych chi erioed wedi cofrestru â Meddyg Teulu y GIG yn y DU?]

Yes

If previously resident in UK, date of leaving [Os oeddech yn arfer byw yn y DU, dyddiad gadael]

Day

Month

Year

Date you first came to live in the UK [Y dyddiad y daethoch gyntaf i fyw yn y DU]

This information is required to complete your registration.

Day

Month

Year

Armed Forces [Lluoedd Arfog]

Have you ever served in the UK Armed Forces? [Ydych chi erioed wedi gwasanaethu fel aelod o luoedd arfog ei mawrhydi?]

Yes [Ydw]

No [Nac Ydw]

If you are returning from the Armed Forces [Os ydych yn dod yn ôl o’r Lluoedd Arfog]

Address before enlisting [Cyfeiriad cyn ymrestru]

Service or Personnel number, BFPO Number [Rhif gwasanaeth neu bersonél, Rhif BFPO]

Enlistment date [Dyddiad ymrestru]

Day

Month

Year

Discharge date [Dyddiad gadael]

Day

Month

Year

If you need your doctor to dispense medicines and appliances* [Os oes angen i’ch meddyg weinyddu meddyginiaeth a theclynnau meddygol*]

*Not all doctors are authorised to dispense medicines [*Nid oes awdurdod gan bob meddyg i weinyddu meddyginiaeth]

I live more than 1 mile in a straight line from the nearest chemist [Rwy’n byw mwy na milltir mewn llinell syth oddi wrth y fferyllydd agosaf]

Yes [Ydw]

I would have serious difficulty in getting them from a chemist [Byddai’n anodd dros ben i mi gael gafael arnynt gan fferyllydd]

Yes [Ydw]

NHS Individual Health Record [Eithrio o Gofnod lechyd Unigol y GIG]

I want to opt out of the Individual Health Record and prevent emergency care medical staff being able to access my key medical information. [Rwy’n dymuno eithrio o’r Cofnod lechyd Unigol ac atal staff meddygol sy’n darparu gofal brys rhag gweld fy ngwybodaeth feddygol allweddol.]

I have received enough information to make an informed decision and I acknowledge that opting out could be detrimental to my healthcare. Further information is available by visiting www.wales.nhs.uk/individualhealthrecord or by calling NHS Direct on 0845 46 47 [Rwyf wedi derbyn digon o wybodaeth i wneud dewis gwybodus ac rwy’n cydnabod y gallai eithrio fel hyn amharu ar fy ngofal iechyd. Mae rhagor o wybodaeth ar gael yn www.wales.nhs.uk/cofnodiechydunigol neu drwy ffonio Galw lechyd Cymru ar 0845 46 47]

I wish to opt out [Rwy’n dymuno eithrio]

I would like to receive correspondence in Welsh [Ticiwch y blwch yma os hoffech chi dderbyn gohebiaeth oddi wrthym yn y Gymraeg]

Yes [Ydw]

Signature [Llofnod]

Your full name(Required)

Electronic signature(Required)

I confirm that by typing my name into the signature box I am electronically signing this form with my own name

Today's date [Dyddiad](Required)

Please select one option below(Required)

Signature of patient [Llofnod y claf]

Signature on behalf of patient [Llofnod ar ran y claf]

Privacy consent

Not for urgent medical help(Required)

Yes, I understand this form is NOT for urgent medical help

IMPORTANT* ( required for you to access treatment and medical advice)(Required)

Please confirm you will come into the surgery within 2 weeks with personal identification documents ( passport or driver's licence) and sign your registration form to complete the registration process. Your registration is not complete until then.

Consent(Required)

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.

I agree to the privacy policy.