New Patient Registration

Everyone is welcome in general practice – lack of ID will not stop you registering at our practice.

You can register online:

by completing the online registration form below. Please be advised it can take up to 10 working days to be registered once you have submitted the form.
through Patient Access. You will need to contact reception first to signup for this service.

Alternatively you can download the registration form here. Once completed please bring it into the surgery.

Temporary Residents

Click here for the form if you need to register as a temporary resident

Patient Details

Have you been registered here before?

Title

Surname

Previous Surname

Forename(s)

Are you

Is your stated gender the same as the gender you were assigned at birth?

Preferred Pronoun

Sexual Orientation

Other Sexual Orientation - please specify

Religion

Date of Birth

Place of Birth

NHS No

Current Address

Current Postcode

How can we contact you? Please tick all that apply

Text

Phone Call

Letter

Home Telephone

Mobile Telephone

Do you have any communication requirements? Please detail below.For example - I require minimum size 14 font in any communications.

Would you like to be registered for Patient Online Access?This allows you see some results and book some of your own appointments online.

Occupation

Status

Previous GP

Previous home address where registered

Date of arrival to the UK if you have never been registered with a GP

Next of kin

Relationship

Contact number

Address

Ethnicity

Please select your ethnicity

Other Ethnicity - Please specify

Is English your main spoken language?

Main Language (if not English)

Health Details

Do you consider yourself to have a disability?

Details of disability

Please give details of your physical/other disability.

Drugs and Alcohol

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 drink any alcohol

How many units per week?(1 unit = ½ pint beer or lager, 1 single measure of spirit or 1 medium glass of wine)

Do you have a drug addiction?

Smoking Status

How many a day?

Would you like support and/or information on giving up?

Family Medical History

Have any of your immediate relatives (brothers/sisters/parents) had any of the following?

Relationship

Please give details and date (if known) below.

Hospital Care

The doctor may discuss with you the possibility of transferring your care to a local hospital

Are you currently under hospital care?

If yes, please complete details below

Hospital name

Name of Consultant

Nature of problem

Other Information

Are you a carer?

Is someone a carer for you?

Females Only

Date of last cervical smear?

Are you pregnant?

Have you had a hysterectomy?

What is your current method of family planning?

Privacy Protection

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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