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Paddington Green | Registeration
Paddington Green
Registeration
Mr
Mrs
Miss
Ms
Name
*
Name
First
First
Last
Last
Gender
*
Male
Female
Indeterminate
Previous Name
Previous Name
First
First
Last
Last
Town and country of birth:
*
Date of Birth:
*
Please use this date format: DD/MM/YYYY.
NHS Number (if known)
Home Address:
*
Postcode:
*
Phone
*
Please help us trace your previous medical records by providing the following information
Previous address in the UK (this help us trace your previous medical records):
Name of the previous GP practice while at that address:
If you are from abroad:
Your frst UK address where registered with a GP:
Date you first came to live in UK:
Please use this date format: DD/MM/YYYY.
If previous resident in UK, date of leaving:
Please use this date format: DD/MM/YYYY.
If you are returning from the armed forces
Address before enlisting:
Service or personnel number:
Enlistment date:
Please use this date format: DD/MM/YYYY
If you are registering a child under 5
I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance
If you need your doctor to dispense medicines and appliances*
*Not all doctors are authorised to dispence medicines
I live more than 1 mile in a straight line from the nearest chemist
I would have serious difficulty in getting them from a chemist
NHS Organ Donor registration
For more information, please ask at reception for an information leaflet or visit the website www.uktransplant.org.uk, or call 0300 123 23 23.
I 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 select all that apply:
Any part of my organs and tissue
Kidney
Heart
Liver
Corneas
Lungs
Pancreas
Any Part of my body
Signature confirming my agreement to organ/tissue donation
NHS Blood Donor registration
For more information, please ask for the leaflet on joining the NHS Blood Donor Register
I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.
I have given blood in the last 3 years
Signature confirming consent to inclusion on the NHS Blood Donor Register
European Economic Area (EEA) Country
For a list of EEA countries visit:
www.gov.uk/eu-eea
Do you live in another EEA country, or have moved to the UK to study or retire, or live in the UK but work in another EEA member state?
Yes
No
Signature
Signature of behalf of Patient
Date
*
Supplementary Questions
I am not ordinarily a resident in the UK
Submit
If you are human, leave this field blank.