On-line Registration Form

We welcome new patient registrations from patients who live within the practice area - mainly Cramlington, Seaton Delaval, New Hartley and Seaton Sluice. To register online please complete this form. You won't need to fill in every section but please check the form carefully and give us as much information as you have available. If you want to register the whole family you will need to submit a form for each family member. The registration cannot be completed until you have visited the surgery to sign the form.

Items with marked with a * are required - all other boxes should be filled in if appropriate  *First name:  *Last name:  Previous last name: *Date of birth DD MM   YY 19 *Place of birth TOWN COUNTRY National Health No. IF KNOWN *Sex MALE FEMALE *Your current address:  *Post code: Home phone no:  Work phone no:   Email: Please help us trace your previous medical records by providing this information where appropriate Your previous address in UK: Name of previous doctor while at that address: Address of previous  doctor: If you are from abroad Your first UK address where registered with a GP If previously resident in UK, date of leaving: DD MM YY Date you first came to live in UK: DD MM YY If you are returning from the Armed Forces Your address before enlisting Service or Personnel number: Enlistment date: DD MM YY If you are registering a child under 5 I wish the child above to be registered with the doctor named below 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 *Not all doctors are authorised to dispense medicines I would have serious difficulty getting them from a chemist NHS Organ Donor registration I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplant after my death. Please tick a appropriate Please do not use if you are filling in this form for someone else. Kidneys Heart Liver Corneas Lungs Pancreas Any part of my body Doctor Please submit this registration to: no preference Dr Alan Dove Dr Chris Ward Dr Chris Prank Dr Anne Green Dr Becky Wright Dr Sarah Jones Dr Aamir Munir Signature We will require the patient named in this form to sign in person at the surgery or on a doctor's first home visit. Please indicate the capacity in which you have completed this form. I have filled in this form on my own behalf I have filled in this form on behalf of: my child a relative a friend   My name is: