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You can register online:
Alternatively you can download the registration form here. Once completed please bring it into the surgery.
Alcohol - alcohol use can affect your health and can interfere with certain medications and treatments. Yours answers will remain confidential so please be honest.
Do you have, or have had any serious health problems (including operations/long term conditions)?
If yes, please hand in at Reception. If no then list below any current medication you are taking and make sure you show Reception all your medication in its original packaging and labelling. We may need to contact your previous GP surgery to confirm your medication.
Have any of your immediate relatives (brothers/sisters/parents) had any of the following?
The doctor may discuss with you the possibility of transferring your care to a local hospital
If yes, please complete details below
How would you describe your ethnicity?
Please provide details of all vaccinations (including dates)
If taking repeat medication
If you have COPD/Asthma
If you have Diabetes
If you have heart disease or high blood pressure
If you want to quit smoking
If you are under hopsital care
Appointment with GP required
Appointment with Nurse required
Appointment with Nurse or Health Care Assistant required
Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.
All Information submitted through secure forms is secured with a private key known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
I consent to my information being used for the purposes described above and wish to submit this online form to New Islington Medical Practice • Ancoats Primary Care Centre, Old Mill Street, Manchester, M4 6EE.
Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.
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