Surname
*
First names
*
Previous names
Date of birth
*
NHS No.
Town and country of birth
*
Telephone number
*
Name of previous doctor while at that address
*
Address of previous doctor
*
If previously resident in UK, date of leaving
Date you first came to live in UK
*
Service or Personnel number
Enlistment date
If you need your doctor to dispense medicines and appliances
Signature
*
Date
*
Signature confirming my agreement to organ/tissue donation
Date
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.
Date
My preferred address for donation is: (only if different from above, e.g. your place of work)
I declare that the information I give on this form is correct and complete. I understand that if it is not correct, appropriate action may be taken against me. A parent/guardian should complete the form on behalf of a child under 16.
Signed:
Date
Print name:
Relationship to patient:
Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.
Country Code:
3: Name
4: Given Names
5: Date of Birth
6: Personal Identification Number
7: Identification number of the institution
8: Identification number of the card
9: Expiry Date
PRC validity period (a) From:
(b) To:
If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.
How will your EHIC/PRC/S1 data be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process. Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.