Iarratas chun Clárú go Buan le Cleachtas Leighis Ginearálta
Ní mór an fhoirm seo a chomhlánú chomh hiomlán agus is féidir.
1. Sonraí Pearsanta
2. Faisnéis chun cabhrú linn do thaifid sláinte Dochtúirí Teaghlaigh roimhe seo a rianú
3. Más ó thar lear tú
4. Má tá tú tar éis fónamh i bhFórsaí Armtha HM
5. Seiceálacha
6. Síniú
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.
Teastaíonn uainn anois go dtabharfaidh tú cruthúnas ar d’aitheantas agus do sheoladh. Iarraimid 2 rud:
(1) grianghraf de do phas nó ceadúnas, cruthúnas ar do ainm MP tiomána;
agus (2) grianghraf de bhille fóntais nó déanaí comhchosúla, ó am éigin i rith na 3 mhí anuas, cruthúnas MP de do cyfeiriad cyfredol.
Tabhair faoi deara gréasáin tattoo defnyddio míreanna Dese unwaith chun críocha fíoraithe Nuair a bhunú suas do chuntas, agus gréasáin a scriosadh do téamaí cuntas MP MP Go gairid ísle oscailte.