Update personal details (Welsh) – Standard Form Test Site

Your details [Eich manylion]

Title [Teitl](Required)

Mrs

Miss

Other [Arall]

Other [Arall](Required)

NHS Number (if known) [Rhif GIG (os ydych chi’n ei wybod)]

Get help to find your NHS number online. [Cymorth i ddod o hyd i’ch rhif GIG ar-lein.]

Name [Enw](Required)

First [Cyntaf] Last [Olaf]

Date of birth [Dyddiad geni](Required)

Day [Dyddiad]

Month [Mis]

Year [Blwyddyn]

Sex [Rhyw](Required)

Male [Gwryw]

Female [Benyw]

Which details would you like to change today? [Pa fanylion yr hoffech eu newid heddiw?](Required)

Your mobile number [Eich rhif ffôn symudol]

Your home telephone number [Rhif ffôn y cartref]

Your address [Eich cyfeiriad]

Your email address [Eich cyfeiriad e-bost]

Your ethnic group/background [Eich grŵp ethnig / cefndir]

Your address details [Manylion eich cyfeiriad]

Please provide your previous address and your new address details in the boxes below. [Rhowch eich cyfeiriad blaenorol a manylion eich cyfeiriad newydd yn y blychau isod.]

Previous address [Cyfeiriad blaenorol]

Previous postcode [Cod post blaenorol]

Your new address [Eich cyfeiriad newydd]

Your new postcode [Eich cod post newydd]

Home telephone number [Rhif ffôn y cartref]

Please provide your old and new home telephone numbers in the boxes below. [Darparwch eich hen rifau a’ch rhifau ffôn cartref newydd yn y blychau isod.]

Old home telephone number [Hen rif ffôn y cartref]

New home telephone number [Rhif ffôn newydd y cartref]

Mobile telephone number [Rhif ffôn symudol]

Please provide your old mobile number (if known) and your new mobile number in the boxes below. [Darparwch eich hen rif symudol (os yw'n hysbys) a’ch rhif symudol newydd yn y blychau isod.]

Old mobile telephone number (if known) [Hen rif ffôn symudol (os yn hysbys)]

New mobile telephone number [Eich rhif ffôn symudol newydd]

Your email address [Eich cyfeiriad e-bost]

Old email address [Hen gyfeiriad e-bost]

Enter Email [Nodwch eich e-bost] Confirm Email [Cadarnhewch eich e-bost]

New email address [Cyfeiriad e-bost newydd]

Enter Email [Nodwch eich e-bost] Confirm Email [Cadarnhewch eich e-bost]

Your ethnicity [Eich ethnigrwydd]

Your ethnic group/background [Eich ethnigrwydd/cefndir]

White - British [Gwyn - Prydeinig]

White - Irish [Gwyn - Gwyddelig]

White - Irish Traveller [Gwyn – Teithiwr Gwyddelig]

White - Traveller [Gwyn - Teithiwr]

White - Gypsy/Romany [Gwyn – Sipsi/Romani]

White - Polish [Gwyn - Pwylaidd]

Any other white background [Unrhyw gefndir gwyn arall]

Mixed - White and Black Caribbean [Cymysg – Gwyn a Du Caribïaidd]

Mixed - White and Black African [Cymysg - Gwyn a Du Affricanaidd]

Mixed - White and Asian [Cymysg - Gwyn ac Asiaidd]

Any other Mixed background [Unrhyw gefndir Cymysg arall]

Asian or Asian British - Indian [Asiaidd neu Asiaidd Prydeinig - Indiaidd]

Asian or Asian British - Pakistani [Asiaidd neu Asiaidd Prydeinig – Pacistanaidd]

Asian or Asian British - Bangladeshi [Asiaidd neu Asiaidd Prydeinig – Bangladeshaidd]

Any other Asian background [Unrhyw gefnid Asiaidd arall]

Black or Black British - Caribbean [Du neu Du Prydeinig – Caribïaidd]

Black or Black British - African [Du neu Du Prydeinig – Affricanaidd]

Black or Black British - Somali [Du neu Du Prydeinig – Somaliaidd]

Black or Black British - Nigerian [Du neu Du Prydeinig – Nigeriaidd]

Any other Black background [Unrhyw gefndir Du arall]

Other ethnic group - Chinese [Cefndir ethnig arall – Tsieineaidd]

Other ethnic group - Filipino [Cefndir ethnig arall – Ffilipinaidd]

Any other ethnic group - [Unrhyw gefndir ethnig arall]

Not stated (Not stated should be used where the person has been given the opportunity to state their ethnic category but chose not to) [Heb ei nodi (Dylid defnyddio "Heb ei nodi" pan roddwyd cyfle i’r person nodi ei gategori ethnig ond dewisodd beidio â gwneud hynny).]

Please state your ethnic group or background *

Other members of your family [Aelodau eraill o’r teulu]

Do you need to change the details for any other members of your household who are registered with this practice? [A ydych angen newid manylion unrhyw aelodau eraill o’ch cartref sydd wedi’u cofrestru gyda’r practis hwn?](Required)

Yes [Oes]

No [Nac oes]

Name 1 [Enw 1]

First [Cyntaf] Last [Olaf]

Date of birth 1 [Dyddiad geni 1]

Day [Dyddiad]

Month [Mis]

Year [Blwyddyn]

Please state ethnic group or background 1 [Nodwch grŵp ethnig neu gefndir 1]

Name 1 - Is this person an adult (over the age of 16 years)? [Enw 1 – Yw’r person hwn yn oedolyn (dros 16 oed)?]

Yes [Ydy]

No [Nac ydy]

Name 1 - Please enter their email address (if different from above) [Enw 1 – Nodwch eu cyfeiriad ebost (os yn wahanol i’r uchod)]

Enter Email [Enter Email [Nodwch eich e-bost] Confirm Email [Cadarnhewch eich e-bost]

Name 1 - Please enter their mobile number (if different from above) [Enw 1 - nodwch eu rhif ffon symudol (os yn wahanol i’r uchod)]

Do you need add another family member (2)? [Ydych angen ychwanegu aelod arall o’r teulu?]

Yes [Nac]

No [Nac oes]

Name 2 [Enw 2]

First [Cytaf] Last [Olaf]

Date of birth 2 [Dyddiad geni 2]

Day [Dyddiad]

Month [Mis]

Year [Blwyddyn]

Please state ethnic group or background 2 [Nodwch grŵp ethnig neu gefndir 2]

Name 2 - Is this person an adult (over the age of 16 years)? [Enw 2 – Yw’r person hwn yn oedolyn (dros 16 oed)?]

Yes [Oes]

No [Nac oes]

Name 2 - Please enter their email address (if different from above) [Enw 2 - nodwch eu rhif ffon symudol (os yn wahanol i’r uchod)]

Enter Email [Nodwch eich e-bost] Confirm Email [Cadarnhewch eich e-bost]

Name 2 - Please enter their mobile number (if different from above) [Enw 2 - nodwch eu rhif ffon symudol (os yn wahanol i’r uchod)]

Do you need to add another family member (3)? [Ydych angen ychwanegu aelod arall o’r teulu?]

Yes [Oes]

No [Nac oes]

Name 3 [Enw 3]

First [Cyntaf] Last [Olaf]

Date of birth 3 [Dyddiad geni 3]

Day [Dyddiad]

Month [Mis]

Year [Blwyddyn]

Please state ethnic group or background 3 [Nodwch grŵp ethnig neu gefndir 3]

Name 3 - Is this person an adult (over the age of 16 years)? [Enw 3 – Yw’r person hwn yn oedolyn (dros 16 oed)?]

Yes [Oes]

No [Nac oes]

Name 3 - Please enter their email address (if different from above) [Enw 3 - nodwch eu rhif ffon symudol (os yn wahanol i’r uchod)]

Enter Email [Nodwch eich e-bost] Confirm Email [Cadarnhewch eich e-bost]

Name 3 - Please enter their mobile number (if different from above) [Enw 3 - nodwch eu rhif ffon symudol (os yn wahanol i’r uchod)]

Do you need to add further family members (4)? [Ydych angen ychwanegu aelod arall o’r teulu?]

Yes [Ydy]

No [Nac ydy]

Additional family members [Aelodau ychwanegol o’r teulu]

If you need to add further family members to this form please use the space below to add their full name and date of birth and any changes you would like to report. [Os ydych angen ychwanegu aelodau teulu pellach i'r ffurflen hon, defnyddiwch y gofod isod i ychwanegu eu henw llawn a'u dyddiad geni, a'r newidiadau yr hoffech chi eu hadrodd.]

Do you consent to receive SMS text messages from the practice? [Ydych chi’n cydsynio i dderbyn negeseuon testun SMS gan y practis?](Required)

Yes [Ydy]

No [Nac ydw]

Do you consent to receive emails from the practice? [Ydych chi’n cydsynio i dderbyn e-byst gan y practis?](Required)

Yes [Ydy]

No [Nac ydw]

Not for urgent medical help [Nid ar gyfer cymorth meddygol brys](Required)

Yes, I understand this form is NOT for urgent medical help [Ie, rwy’n deall NAD yw’r ffurflen hon ar gyfer cymorth meddygol brys]

Consent [Caniatâd](Required)

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website. [Trwy gyflwyno eich manylion, rydych yn cydsynio i ddarparu’r wybodaeth hon i wella ein gwasanaethau i chi. Bydd y data a ddarperir gennych ar y ffurflen hon yn cael ei storio’n ddiogel ar ein gwefan, sy’n cael ei chynnal gan drydydd parti. Ni fyddwn yn cadw’r wybodaeth hon ar y wefan am fwy na 7 diwrnod calendr. Ni fydd eich manylion cyswllt yn cael eu gwerthu nac eu rhannu â thrydydd parti. Rwy’n deall y gallaf ddirymu’r cydsyniad hwn ar unrhyw adeg trwy gysylltu â’r practis. Gellir gweld ein polisi preifatrwydd ar y wefan hon.]

I agree to the privacy policy. [Rwy’n cydsynio i’r polisi preifatrwydd]