Date of Birth:
Town & country of birth:
Your previous address in UK:
Are you from abroad?
Your first UK address where registered with a GP:
Date you first came to live in UK
Are you returning from the Armed Forces?
Address before enlisting
Service or Personnel Number
If you are registering a child under 5
Please tick the box if you have any of the following...
Please list any other operations or serious illnesses you have had:
Has anyone in your immediate family under the age of 60 suffered from heart disease or stroke? Please give details of relationship and age when diagnosed.
Please list any allergies to medication you have:
If you are interested in help to stop smoking, please book in at reception for the Smoking Cessation Clinic
How often do you have a drink containing alcohol?
How many standard drinks containing alcohol do you have on a typical day when drinking?
How often do you have six or more drinks on one occasion?
How tall are you?
How much do you weight?
NHS Organ Donor registration
I want to register my details on the NHS Organ Donor Register as someone whose organ/tissue may be used for transplantion after my death.
Please tick the boxes that apply
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.