Application to Register Permanently with a General Medical Practice
This form must be completed as fully as possible.
1. Personal Details
2. Information to Help Trace Your Previous GP Health Records
3. If you are from abroad
4. If you have served in HM Armed Forces
5. Checks
6. Signature
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.
We now need you to provide proof of your identification and your address. We ask for 2 things:
Step 1
A photo of your passport or driving licence, as proof of your name;
Step 2
A photo of a recent utility bill or similar, from sometime over the past 3 months, as proof of your current address.
Please note that we use these items once for verification when setting up your account, and we delete them as soon as your account is open.