Family doctor services registration If you would like to register at the practice then please make sure that you meet our requirements before completing this form. Patient's details - By completing this form you are also consenting to opting in for electronic communications from the Sandmere Practice Please complete all the fields to ensure the form can be sentTitle*MrMrsMissMsEmailSurname*First name(s)*Previous surname/sDate of birth* Date Format: MM slash DD slash YYYY NHS NumberTown and country of birth*Gender*MaleFemaleHome address*Postcode*Telephone number*Please help us trace your previous medical records by providing the following informationYour previous address in UKName of previous doctor while at that addressAddress of previous doctorIf you are from abroadYour first UK address where registered with a GPIf previously resident in UK, date of leaving Date Format: MM slash DD slash YYYY Date you first came to live in UK Date Format: MM slash DD slash YYYY If you are returning from the Armed ForcesAddress before enlistingService or Personnel numberEnlistment date Date Format: MM slash DD slash YYYY If you are registering a child under 5 I wish the child above to be registered with the doctor named overleaf for Child Health Surveillance If you need your doctor to dispense medicines and appliances I live more than 1 mile in a straight line from the nearest chemist I would have serious difficulty in getting them from a chemist Note: Not all doctors are authorised to dispense medicinesAre you completing this form as the patient or on behalf of the patient?*PatientOn behalf of patientNHS Organ Donor registration Yes No 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. You will need to complete and sign a form at the surgery.NHS Blood Donor registration Yes No I would like to join the NHS Blood Donor Register as someone who may be contacted and would be prepared to donate blood. You will need to complete and sign a form at the surgery.