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LOCKSIDE MEDICAL CENTRE

85 Huddersfield Road, Stalybridge SK15 2PT

Telephone: 0161 303 7200

We are open, Please follow the Green Tile (Request help including Appointments) on the Home page to fill out the online consultation form. Thank You

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New Registration Additional Info

New Patient 16+ ONLY Blood Pressure Reading

This form has been created by Lockside as part of our Pre-registration questionnaire. We would like to ask our new patients aged 16 & above to provide an up to date blood pressure reading. If you do not have a blood pressure monitor of your own you can call in to any local chemist or pop in to the practice to use our waiting room machine.

Name(Required)

First Last

Date of Birth(Required)

Phone

Address

Street Address Address Line 2 City County / State / Region Postcode Country

Blood Pressure Reading(Required)

If you do not have a monitor of your own you can attend any local pharmacy or pop in to the surgery and use our machine in reception. PLEASE NOTE: If you have a reading 140/90 please let reception know.

Lockside Medical Centre

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"*" indicates required fields

Name

This field is for validation purposes and should be left unchanged.

Name*

Prefix First Last

I would like to update my name.

Tick here for more options.

You do not need to provide a reason for this change, but an example could be marriage/divorce or changes made by deed poll.

New Name

Prefix First Middle Last

You do not need to provide a reason for this change, but an example could be marriage/divorce or changes made by deed poll.

Date of Birth*

Address (Current/Previous)*

Street Address Postcode Country

This should match the address we have on file for you.

TICK HERE*

My address remains the same.

I need to update my address.

New Address

Street Address Postcode Country

Please provide the Name & DOB of ANY members of your household that have moved to the same address.*

ONLY REQUIRED IF YOU ARE PROVIDING A CHANGE OF ADDRESS and family members are currently registered with us. Please note 'NA' if this is not applicable to you.

Phone (Current/Previous)*

Email (Current/Previous)*

TICK HERE*

My contact details remain the same.

I need to update my contact details.

New Phone Number

New Email*

Smoking Status*

How many a day?*

How often?*