Pre registration form Patient's DetailsTitle Mr Mrs Miss Ms Mx Other SurnameDate of Birth Optional DD slash MM slash YYYY First Name(s)NHS NumberPrevious Surnames OptionalGender Male Optional Female Optional Other Optional Town and Country of birthHome AddressPostcodeTelephone numberPlease help us trace your previous medial records by providing the following informationYour previous address in UK OptionalName of previous GP practice while at that address OptionalAddress of previous GP practice OptionalIf you are from abroadYour first UK address where registered with a GP OptionalIf you previously resident in UK, date of leaving OptionalDate you first came to live in UK OptionalWere you ever registered with an Armed Forces GPPlease indicate if you have served in the UK Armed Forces and/or been registerd with a Ministry of Defence GP in the uk or overseas Regular Optional Reservist Optional Veteran Optional Family Member (Spouse, Civil Partner, Service Child) Optional Address before enlisting OptionalService or Personnel Number OptionalPostcode OptionalEnlistment date Optional DD slash MM slash YYYY Discharge date (if applicable) Optional DD slash MM 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 Optional I would have serious difficulty in getting them from a chemist Optional *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 Optional Kidneys Optional Heart Optional Liver Optional Corneas Optional Lungs Optional Pancreas Optional Please 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 decisionNHS Blood Donor registration Yes I would like to join the NHS Blood Donor Register Optional Tick here if you have given blood in the last 3 years Optional I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate bloodMy preferred address for donation is: (only if different from above, e.g. your place of work) Optional