HTML Preview Sexual Health Infirmary Patient template page number 2.
S/GUM/clinic forms from May 2012/Self Assessment Forms/May 2012
INTEGRATED SEXUAL HEALTH – CARDIFF ROYAL INFIRMARY
REGISTRATION FORM
PLEASE PRINT CLEARLY
SURNAME: FIRST NAME (S):
ADDRESS:
CONTACT: YES/ NO
MOBILE
TEL NO:
POSTCODE:
HOME
TEL N0:
DATE OF BIRTH:
SINGLE/MARRIED/SEPARATED/DIVORCED/
LIVING WITH PARTNER/WIDOWED:
COUNTRY OF BIRTH:
OCCUPATION:
GP NAME & ADDRESS:
PERMISSION TO CONTACT
GP YES / NO
(In extreme circumstances,
if we are unable to contact
you regarding treatment of
an infection it may be
necessary to contact your
General Practitioner)
Ethnicity (cross one box) (this information is
required for our statistics):
White
Black or Black British
Caribbean African Other
Asian or Asian British
Bangladeshi Pakistani Indian
Chinese Other
Unknown
Any other ethnicity
Which? ……………………………………
HOW LONG HAVE YOU LIVED IN THE UK?
ARE YOU SEEKING ASYLUM
HERE? YES / NO
If receiving text I undertake to inform the clinic if I sell my mobile phone or change
the number. I understand that the clinic is not responsible if messages arrive on
the phone at a time when it is not in my possession.
I AGREE / DO NOT AGREE TO RECEIVE MY RESULTS BY TEXT
Signed……………………………………………..Dated…………………………………………
PLEASE ENTER A PERSONAL PASSWORD FOR SECURITY PURPOSES
…………………………………………………………………………………………