For the following questions please answer to the best of your knowledge: We have provided a basic guide to alcohol content below to assist your completion:

A 750ml bottle of wine contains 10 units.

A standard (175ml) glass of wine contains 2 units.

A single small shot of spirits (25ml) contains 1 unit.

A standard 70cl bottle of spirits contains 28 units.

A pint of 3.6% strength lager/beer/cider contains 2 units.

A pint of 5.2% strength lager/beer/cider contains 3 units.

Please tell us your most recent measurements for the following (if known)

Please note, we may contact you to offer you support or advice if appropriate based on your submission.

Is there any of the following in your family (father, mother, brother, sister) before the age of 65?

At Riverside Medical Practice, we are committed to promoting access to our services and offering choice wherever possible in the services we provide, and the way we deliver them. An acceptable behaviour contract is an individual written agreement between a patient and their GP Practice.

The contract is between the patient named above and Riverside Medical Practice and is valid from the date of application to register as a patient at the surgery.

1. I agree to attend all appointments on time and/or cancel any appointments I am unable to attend, giving as much notice as possible (no later than 1 hour before the appointment time). 2. I agree to the Riverside Medical Practice DNA (Did Not Attend) policy – if after I have missed 2 appointments without notifying the surgery, I will receive a warning letter. If I then miss 1 more appointment within 12 months, I will be removed from the practice list and will have to register with a different practice. 3. I agree to adhere to the Riverside Medical Practice repeat prescription policy and agree to allow 72 hours before collecting my prescription. 4. I agree to treat the GPs and their staff at Riverside Medical Practice, fellow patients and their carers and visitors politely and with respect at all times. 5. I agree to not smoke, consume alcohol and/or take non-prescribed medication or drugs whilst on NHS premises 6. I agree to refrain from using abusive or offensive language, making threats of violence or aggressive behaviour and to treat all staff fairly and with respect, in person, on the phone, in writing or on social media. 7. I accept and understand that the GPs of Riverside Medical Practice are obliged to provide a safe and secure environment for its entire staff and care for their health and safety, and I accept and understand that no member of staff must jeopardise their own safety in providing me care.

I understand that if I fail to adhere to the above conditions, I will be removed from the practice list. This contract serves as an initial warning in the event of breaches occurring. I accept that the GPs and staff at Riverside Medical Practice will only restrict or withdraw my rights to care in exceptional circumstances, or if I have failed to comply with ant of my responsibilities listed above. As a patient I accept that I can lose my right to receive mainstream NHS patient care services. When removal results from no: 6 above, any patients for whom I am responsible, ie. child or cared for individual and who live at the same address, will also be removed to avoid any risk of further abuse to clinicians undertaking home visits for said child or cared for individual.

Have a duty of care to you as a patient and aim to provide appropriate and effective healthcare service and treatment to you, to meet your needs at all times. Aim to provide healthcare services that are sympathetic to my individual needs within the resources which the Aneirin Bevan Health Board (ABHB)/Primary Care Contractor has available. Treat you with courtesy and respect, and ensure you are dealt with quickly, fairly and in a helpful manner. Ensure that staff take responsibility for resolving or dealing with your query, and/or that they refer to an appropriate colleague.

Thank you for completing