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Withington Medical Practice NHS GP Surgery in Manchester

Child new patient registration

Child 0-16 yrs Registration Form

Child’s Personal Details:

Child Title: *

Mrs

Miss

Child surname: *

Child first names: *

Child previous surname(s):

Email address: *

Any responses we send shall be sent to this email address.

Child date of birth: *

Please use this date format: DD/MM/YYYY

Child NHS number (if known):

Child town and country of birth: *

Child hospital/place of birth: *

If you are from abroad, please state the date you came to the UK:

Please use this date format: DD/MM/YYYY

Child gender: *

Male

Female

Non Binary

Child’s current Manchester address: *

How long will you be at this address: *

Less than 6 months

More than 6 months

Home telephone: *

Work telephone:

Mobile telephone:

Text Messages

Text messages will include appointment reminders, health promotion and information, seasonal clinic information and research opportunities (your preference can be changed at a later date should you change your mind).

Do you consent to be contacted by text message? *

Yes

If you are human, leave this field blank.

4-6 Copson Street
Manchester
M20 3HE

Get directions

0161 434 2753

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