Thursday, 19 October 2017
YSTWYTH MEDICAL GROUP
Mothers Maiden Name
Date of Birth
Town and country of birth
Please help us trace your previous medical records by providing the following information
- 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
Are you coming from abroad?
Have you registered with a NHS GP in the UK?
address where registered with a
If previously resident in
, date of leaving
Date you first came to live in
Are you returning from the Armed Forces?
Address before enlisting
Service or Personnel number
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
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)
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.