Health Centre Online Registration

Please fill in your details and click Submit when complete.

Please only complete this registration form once. If you have previously submitted this form at any time please
do not do so again unless advised by the Surgery to do so. If you are unsure of your registration status,
you can contact the practice who will be able to confirm this for you.

Current patients: DO NOT use this form to update your address or other details.

* Your preferred language:	Cymraeg   English
* Which PRACTICE would you like to register with?	Please select... Church Surgery Padarn Surgery Ystwyth Medical Group
* Have you ever registered with this practice before?	Yes   No
Title:	Mr   Mrs   Miss   Ms   Mx
* Surname (Family name):
* First name(s):
Preferred (known as) first name: (if different from above)
Previous surname(s):
Mother’s maiden name:
* Date of birth:	Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916
NHS No. (if known):
* Gender assigned at birth:	Male   Female
* Town and country of birth:
Please fill in your ADDRESS:
Room/Flat/Block:
House:
* Street Address:
* Town:
* Postcode:
* Email address:
* Confirm Email address:
* UK Mobile telephone number:
* Contacting you I consent to being contacted via Email and/or Text Message with appointment reminders or routine clinic invitations: I decline to being contacted via Email and/or Text Message with appointment reminders or routine clinic invitations:
Please help us trace your medical records by selecting if you are from the UK or from Abroad (Part 1) and then filling in the next section (Part 2)
* Part 1. Select if you are from UK or abroad:	from UK from Abroad
Part 2: Fill in if you come from the UK * Previous Address in UK: (i.e. the address your current GP have for you) * Town: * Postcode: * Name of Doctor or Surgery when at that address: * Address of Doctor or Surgery: Postcode:
* Are you currently in the UK?			Yes   No
You cannot register with us until you are in the UK
Part 2: Fill in if you come from abroad * Date when you arrived in UK: Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Visa expiry date: (if appropriate) Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 * Have you been registered with a GP in the UK before? Yes    No Your UK last address when registered with a GP: (only if you have previously registered with a GP) Town: Postcode: If a previous resident in UK, date of leaving: Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Details of person to be contacted in an emergency
* Name:
* Telephone:
Have you ever served in HM ARMED FORCES?		Yes   No
* Signature:	Clear
Health Questionnaire
Ethnic origin: Please select... British or mixed British Irish Other White background Indian or British Indian Pakistani or British Pakistani Bangladeshi or British Bangladeshi Other Asian background Caribbean African Other Black background Chinese White and Asian White and Black Caribbean White and Black African Other mixed background Other (please specify) Not stated Other:
* Height: cm * Weight: kg
Do you have any HEALTH PROBLEMS ?Yes   No  (including asthma, diabetes, mental health etc) Please state any health problems you have:
Do you have any ALLERGIES ?Yes   No  Please state any allergies you have:
Do you take any MEDICATION at present?Yes   No  Please list any prescribed medicines you use including Name, Dosage and Quantity:
How many units of ALCOHOL do you drink per week? How to calculate units of alcohol.
* Do you SMOKE? Yes   Never   Used to smoke (not now)
* Amount you smoke per day:   Please select... Less than 1 per day 1 to 9 per day 10 to 19 per day 20 to 39 per day 40 or more per day We offer advice on smoking and a smoking cessation clinic in the surgery. Please indicate if you like information on this:
VACCINATIONS
Please indicate if you have/have not had the following:
Meningitis C: Yes, date: No MMR (measles, mumps, rubella): Yes, date: No Tuberculosis: Yes, date: No DTP and Polio: Yes, date: No
Please read our Privacy Notice.

The information you are submitting will be sent encrypted to the medical practice over the Internet, which still isn't 100% secure.
If you are worried about this you can instead obtain a form from the medical practice that can be filled in and delivered by hand.
* = Compulsory.