The Wiggly Demo Surgery -

NHS Organ Donor registration

I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death.

Please tick as appropriate

Any part of my body

Please note a signature will be required for this section of the form confirming consent to organ donation.

This is an urgent notice that can be displayed on your website - perhaps it can say FLU CLINICS BEING BOOKED NOW!

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Registration

This is your pre-configured online registration page, don't forget you don't have to use it if you do not think it is suitable for your surgery. It can be turned off very easily, if you change your mind it's not a problem you simply turn it back on!

As with all form pages you can display text above and below the form. So you can use these areas to display your practice registration policy or give particular instructions if you wish.

You will need to complete one of these forms for each person you wish to register with our Practice. Those fields marked with an * are required.

	Family doctor services registration
Patient's details

Title:	Mr Mrs Miss Ms	Surname:	*
Date of Birth:	D M Y *	First Names:	*
NHS No:		Prev Surname:
Sex:	Male Female	Ethnicity:	*
Town and Country of Birth:	*	First Spoken Language:	*
	For those people who were born in London, please state your borough.
Home Address:	*
Postcode:		Tel Number:	*
Email address:		Mobile Number:

Please help us trace your previous medical records by providing the following information

Your previous address in UK	Name of previous doctor while at that address
*
	Address of previous doctor


If you are from abroad

Your first address where registered with a GP

If previously resident in UK, date of leaving	Date you first came to live in the UK
D M Y	D M Y

If you are from the Armed Forces

Address before enlisting	Enlistment date
	D M Y
Service or Personnel number	Discharge date
	D M Y

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 dispense medicines.
I live more than 1 mile in a straight line from the nearest chemist
I would have serious difficulty in getting them from the chemist

Family doctor services registration

NHS Blood Donor registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood.

Tick here if you have given blood in the last 3 years

Please note a signature will be required for this section of the form confirming consent to inclusion on the NHS Blood Donor Register.

Emergency Contact
Name:		Relationship:
Address:		Tel No:

Please complete the following:

I have filled in this form on my own behalf

I have filled in this form on behalf of

My name is

Code:

Enter the characters as seen on the image above (case insensitive):

GP Website from Wiggly-Amps Ltd.