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Mr/Mrs/Miss/Ms * Surname:
Email address:
Please help us to trace your previous medical records by providing the following
information:
Name and address of your previous doctor whilst at the above address:
YES/NO* I wish the child above to be registered for Child Health Surveillance
NHS Organ Donor registration
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 indicate organs/tissue you would like to donate:-
Date: ................................................
For more information please ask at reception for an information leaflet or visit the website
www.uktransplant.org.uk, or call 0845 60 60 400
FAMILY DOCTOR SERVICES REGISTRATION GMS1 Page 2
Please complete in block capitals and *delete as appropriate
Have you given blood in the last 3 years YES/NO* If yes please give date:
Date: ..................................................................
For more information, please ask for the leaflet on joining the NHS Blood Donor Register.
I am on the HS CHS list and will provide Child Health Surveillance to this patient*
I have accepted this patient on behalf of the doctor named below, who is a member of this
Practice and is on the HS CHS list and will provide Child Health Surveillance to this patient
I declare to the best of my belief this information is correct and I claim the appropriate payment as set out
in the Statement of Fees and Allowances. An audit trail is available at the Practice for inspection by the
HAs authorised offices and auditors appointed by the Audit Commission.
Practice Stamp:
Dr Kenyon & Partners
19 Beaumont Street
OXFORD
OX1 2NA