MEDICAL DECLARATION

Mae’r ffurflen gais hon hefyd ar gael yn Gymraeg / This application form is also available in Welsh

Full name:     

Date of birth:                                       Place of birth:      

Maiden name:                                     Any other surnames:      
                                                                               
Your current full address:      

Postcode:                              

Tel. No:                             E-mail address:                        Fax No:        

The name and address of your general medical practitioner: 

Name:      

Address:      

Postcode:                   

Tel. No:      

Tell us about anything for which your general medical practitioner or hospital is treating you at the moment.  This should include all treatments you are receiving for your physical, emotional or mental health; 

     

…and details of any hospital admissions in the past five years;

     

…and any serious physical, emotional or mental illness within the five year period before the date of the application;

     

The information given above is, as far as I know, full and true.  I hereby give you permission to ask my GP and any other medical practitioner to check this information and give them permission to add any information which they believe should be disclosed to assist you in making a properly informed decision on my application to become registered.  As there may be a charge for this I agree to pay any fee(s) required by the medical practitioners involved.

Signed:                                                                             Date:      

Important: 
We process any personal and/or sensitive information we hold about you fairly and lawfully, and we only ask for such information where it is necessary for us to carry out our role. For more information about how we process your personal data, and your rights in relation to this, please see our Privacy Notice at https://careinspectorate.wales/how-we-use-your-information, or contact us for a paper copy.

To be returned in a sealed envelope marked confidential bearing your full name

ACCESS TO MEDICAL REPORTS ACT 1988
You may ask to see any report compiled by your doctor/specialist before it is supplied to us.  You will have 21 days from the date you return this form to us to ask your doctor /specialist for access to their report before they send it to us.  If you do this they will not send the report to us until you have given your agreement.  If you regard any part of their report as incorrect or misleading, you can ask for it to be changed.  Your doctor/specialist is not obliged to change their report but if they don’t you will be invited to prepare a written statement on the disputed information for attachment to their report.  If this happens, it may add to the time it takes to consider your application.