Bone Marrow Register - Collection.europarchive.org
Bone Marrow Register - Collection.europarchive.org
Bone Marrow Register - Collection.europarchive.org
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Personal details Please print clearly in black ink, using block capitals<br />
Title: Mr/Mrs/Ms/Miss/Other ______________________________________________________<br />
First name/s _____________________________________________________________________<br />
Last name ______________________________________________________________________<br />
Date of Birth (DD/MM/YY) _______________________________________________________<br />
Address _________________________________________________________________________<br />
_________________________________________<br />
Postcode _____________________________<br />
Home phone number ____________________________________________________________<br />
Work phone number ____________________________________________________________<br />
Mobile phone number ___________________________________________________________<br />
Email address ___________________________________________________________________<br />
Place of usual blood donation session _____________________________________________<br />
Are you a member of any other UK <strong>Bone</strong> <strong>Marrow</strong> Registry <br />
Eg Anthony Nolan Trust Yes No (Please tick one only)<br />
Ethnicity codes<br />
To which ethnic group do you consider that you belong<br />
WHITE<br />
1A UK/other Northern Europe<br />
1B Southern Europe<br />
1D Jewish<br />
1F Americas/Australia/New Zealand<br />
1G Mediterranean<br />
1H Other<br />
BLACK<br />
2I Africa<br />
2J Caribbean<br />
2K American<br />
2L Other<br />
ASIA & MIDDLE EAST<br />
1C Middle Eastern Arab<br />
1E India<br />
1E Pakistan<br />
1E Bangladesh<br />
3M Chinese<br />
3M Japanese<br />
3O Nepalese/Burmese/Thai/Indonesian<br />
3P Other Asian/Middle Eastern<br />
OTHER<br />
4Q South America<br />
4R Hispanic<br />
4S Other<br />
www.bbmr.co.uk
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