The Manor Street Surgery

For all patients who wish to register with the practice who are under the age of 16. All children must have a parent or guardian registered at the surgery.

Name of Child
Title First Last
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Telephone Number
Date of Birth

Day
Month
Year
Place of Birth
Have you just entered the country?
Which date did you enter the country?
DD slash MM slash YYYY
NHS Number*
Previous Records
Please provide the following information if you have been registered with the NHS previously.
Your previous address in the UK
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name and address of previous Doctor whilst at that address
Name of Doctor Address of previous Doctor
Nationality*
If you are registering a child under 5
Child Health Surveillance
- I wish the child to be registered for Child Health Surveillance
Submission
Name of parent or guardian submitting form
You must be a registered patient of Manor Street Surgery and live at the same address of the child being registered.
Prefix First Last
Date of birth

Day
Month
Year
Signature:
- Of patient
- On behalf of patient
Signature
Comments
This field is for validation purposes and should be left unchanged.

New Patients: How do I register?

How can I book an appointment?

Online Appointment Booking

Order your Prescriptions

Patient Participation Group

Friends & Family Test

Update your Details

Travel Forms

Opening Times

Monday
08:00 until 18:30
Prebooked telephone appointments available 67am-8am & 6.30-8pm Speak with our reception team
Tuesday
08:00 until 18:30
Wednesday
08:00 until 18:30
Thursday
08:00 until 18:30
Friday
08:00 until 18:30
Saturday
CLOSED
Sunday
CLOSED

Useful Links

The Manor Street Surgery

Registration Form – Childrens

Registration Form - Childrens

Previous Records

If you are registering a child under 5

Submission

Opening Times

Useful Links

Friends & Family Test

Update your Details