Cais i Gofrestru'n Barhaol gyda Phractis Meddygol Cyffredinol
Rhaid llenwi'r ffurflen hon mor llawn â phosibl.
1. Manylion Personol
2. Gwybodaeth i'n helpu i olrhain eich cofnodion iechyd meddygon teulu blaenorol
3. Os ydych o dramor
4. Os ydych wedi gwasanaethu yn Lluoedd Arfog EM
5. Sieciau
6. Llofnod
New Patient Registration/Health Questionnaire
All information supplied will be recorded in your confidential medical records.
Contact Details Smoking Alcohol Height & Weight - Please tell us your most recent measurements for the following (if known). Next of Kin Family History Medication Allergies Past Medical History Carer Information History Special Circumstances Military Veteran Communication We now need you to provide proof of your identification and your address. We ask for 2 things:
Step 1 Step 2 ACCEPTABLE BEHAVIOUR CONTRACT
Dr Waheed & Partners at Pontllanfraith Health Centre, 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 you and Dr Waheed & Partners, Pontllanfraith Health Centre and is valid from the date of application to register as a patient at the surgery.
Rydym yn awr yn rhaid i chi ddarparu prawf o'ch Adnabod a'ch cyfeiriad. Rydym yn gofyn am 3 Pethau:
Cam 1
Llun o'ch pasbort neu drwydded yrru, yn brawf o'ch enw;
Cam 2
Llun o fil diweddar cyfleustodau neu debyg, o'r Rhywbryd yn ystod y 2 mis diwethaf, o ganolfannau prawf o'ch cyfeiriad.
Sylwch rydym yn ei wneud Fod Defnyddiwch yr eitemau hyn delimited gyfer gwirio Wrth sefydlu eich cyfrif, ac rydym yn ei wneud dileu cyn gynted ag y bydd eich cyfrif ar agor.