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New Patient Registration

You can register online:

  • by completing the online registration form below
  • 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.

1Patient Details

2Health Details

Alcohol - alcohol use can affect your health and can interfere with certain medications and treatments. Yours answers will remain confidential so please be honest.

(1 unit = ½ pint beer or lager, 1 single measure of spirit or 1 medium glass of wine)


4Medical History

Do you have, or have had any serious health problems (including operations/long term conditions)?

5Repeat Medication

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.

6Family Medical History

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

7Hospital Care

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

If yes, please complete details below

8Other Information

9Females Only


How would you describe your ethnicity?

11Children Only

Please provide details of all vaccinations (including dates)

12Please book the following appointments if applicable

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 required

Appointment with Nurse or Health Care Assistant required

Appointment with Nurse required

Appointment with GP required

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.

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.

Ancoats Primary Care Centre, Old Mill Street, Manchester, M4 6EE
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