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All fields are required unless stated otherwise.

Patient Details

Forename

Surname

Date of Birth

Please provide at least one of the following

NHS Number

Range: 300 000 0000 - 999 000 0000

CHI & H&C ranges below are unavailable.

CHI Number

Range: 010 100 0000 - 311 299 9999

Your CHI Number starts with your date of birth (dd/mm/yy).

H&C Number

Range: 320 000 0001 - 399 999 9999

Disclamer

1) I agree to the Terms and Conditions

1) I agree to the Terms and Conditions

1) I agree to the Terms and Conditions

1) I agree to the Terms and Conditions

2) I understand the purpose and nature of the Haemtrack system, and give consent for my Local Haemophilia Centre and the National Haemophilia Database (NHD) to hold my treatment data and to analyse it anonymously for research and audit purposes.

I agree to the statement(s) above

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