Thursday, 19 October 2017

YSTWYTH MEDICAL GROUP
01970 613500
Parc-y-Llyn, Aberystwyth
Cofrestru ar-lein

Patient Details


Title


Surname*


First Names*


Previous surname's


Gender


Known Name


Mothers Maiden Name



Date of Birth


NHS No.



Town and country of birth*


Address


Post Code


Telephone number


Email address*


Please help us trace your previous medical records by providing the following information



Previous address


Postcode


- if you do not know the full details of your previous GPs name and address, please fill in as much as you can remember

Name of previous doctor while at that address*


Address of previous doctor*


Abroad


Are you coming from abroad?


Have you registered with a NHS GP in the UK?


Your first UK address where registered with a GP


If previously resident in UK, date of leaving


Date you first came to live in UK


Armed Forces


Are you returning from the Armed Forces?


Address before enlisting


Service or Personnel number


Enlistment date


Discharge date


If you need your doctor to dispense medicines and appliances*


*Not all doctors are authorised to dispense medicines
I live more than 1 mile in a straight line from the nearest chemist
I would have serious difficulty in getting them from a chemist

NHS Organ Donor registration


I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death.
Please tick as appropriate

  • Any of my organs and tissue

  • Kidneys

  • Heart

  • Liver

  • Corneas

  • Lungs

  • Pancreas

  • Any part of my body


NHSBlood Donor registration


I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.


For more information, please ask for the leaflet on joining the NHS Blood Donor Register
Tick here if you have given blood in the last 3 years

My preferred address for donation is: (only if different from above, e.g. your place of work)


Address


Post Code


How to complete the final process?


Click sumbit to generate the registraion form which will need to be printed out, signed and then taken into the practice.