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Fforestfach Medical Centre

01792581666

GMS1w

Patient's details [Manylion y claf]

Title(Required)

Sex(Required)
Date of birth [Dyddiad geni](Required)

Please help us trace your previous medical records by providing the following information [Helpwch ni i olrhain eich cofnodion meddygol blaenorol drwy ddarparu’r wybodaeth ganlynol]

If you are from abroad [Os ydych o dramor]

Have you ever registered with a NHS GP in the UK? [Ydych chi erioed wedi cofrestru â Meddyg Teulu y GIG yn y DU?]
If previously resident in UK, date of leaving [Os oeddech yn arfer byw yn y DU, dyddiad gadael]
Date you first came to live in the UK [Y dyddiad y daethoch gyntaf i fyw yn y DU]

Armed Forces [Lluoedd Arfog]

Have you ever served in the UK Armed Forces? [Ydych chi erioed wedi gwasanaethu fel aelod o luoedd arfog ei mawrhydi?]

If you are returning from the Armed Forces [Os ydych yn dod yn ôl o’r Lluoedd Arfog]

Enlistment date [Dyddiad ymrestru]
Discharge date [Dyddiad gadael]

If you need your doctor to dispense medicines and appliances* [Os oes angen i’ch meddyg weinyddu meddyginiaeth a theclynnau meddygol*]

*Not all doctors are authorised to dispense medicines [*Nid oes awdurdod gan bob meddyg i weinyddu meddyginiaeth]
I live more than 1 mile in a straight line from the nearest chemist [Rwy’n byw mwy na milltir mewn llinell syth oddi wrth y fferyllydd agosaf]
I would have serious difficulty in getting them from a chemist [Byddai’n anodd dros ben i mi gael gafael arnynt gan fferyllydd]

NHS Individual Health Record [Eithrio o Gofnod lechyd Unigol y GIG]

I want to opt out of the Individual Health Record and prevent emergency care medical staff being able to access my key medical information. [Rwy’n dymuno eithrio o’r Cofnod lechyd Unigol ac atal staff meddygol sy’n darparu gofal brys rhag gweld fy ngwybodaeth feddygol allweddol.]
I have received enough information to make an informed decision and I acknowledge that opting out could be detrimental to my healthcare. Further information is available by visiting www.wales.nhs.uk/individualhealthrecord or by calling NHS Direct on 0845 46 47 [Rwyf wedi derbyn digon o wybodaeth i wneud dewis gwybodus ac rwy’n cydnabod y gallai eithrio fel hyn amharu ar fy ngofal iechyd. Mae rhagor o wybodaeth ar gael yn www.wales.nhs.uk/cofnodiechydunigol neu drwy ffonio Galw lechyd Cymru ar 0845 46 47]
Please tick this box if you wish to receive correspondence in Welsh [Ticiwch y blwch yma os hoffech chi dderbyn gohebiaeth oddi wrthym yn y Gymraeg]

Signature [Llofnod]

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Date published: 16th January, 2024
Date last updated: 24th June, 2024