Pre registration formPatient's detailsTitle* Mr Mrs Miss MsSurname*Date of birth* DD slash MM slash YYYY First names*NHS Number*Previous surnamesGender* Male FemaleTown and country of birth*Home address*Postcode*Telephone number*Please help us trace your previous medical records by providing the following informationYour previous address in UKName of previous GP practice while at that addressAddress of previous GP practiceIf you are from abroadYour first UK address where registered with a GPIf previously resident in UK, date of leavingDate you first came to live in UKWere you ever registered with an Armed Forces GPPlease indicate if you have served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas Regular Reservist Veteran Family Member (Spouse, Civil Partner, Service Child)Address before enlistingService or Personnel numberPostcodeEnlistment date DD slash MM slash YYYY Discharge date (if applicable) MM slash DD slash YYYY Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services.If you need your doctor to dispense medicines and appliances* I live more than 1.6km in a straight line from the nearest chemist I would have serious difficulty in getting them from a chemist*Not all doctors are authorised to dispense medicinesI want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death. Please tick the boxes that apply. Any of my organs and tissue or Kidneys Heart Liver Corneas Lungs PancreasPlease tell your family you want to be an organ donor. If you do not want to be an organ donor, please visit www.organdonation.nhs.uk or call 0300 123 23 23 to register your decision.NHS Blood Donor registration Yes I would like to join the NHS Blood Donor Register Tick here if you have given blood in the last 3 yearsI would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.My preferred address for donation is: (only if different from above, e.g. your place of work)All blood types are needed, especially O negative and B negative. Visit www.blood.co.uk or call 0300 123 23 23.
