Tell us whether you accept cookies

We've put some small files called cookies on your device to make our site work. We would also like to use analytical cookies to understand how our site is used and improve user experience. Analytical cookies send information to Google Analytics.

Let us know your preference. We will use a cookie to save your choice. Before you make your choice you can read more about our cookie policy.

Skip to main content

Urban Village Medical Practice NHS GP Surgery in Ancoats

Demographics monitoring

Demographics Monitoring Form

Patient Details

Title:

Mr

Mrs

Miss

Ms

Mx

Other

Please specify:

First Name: *

Last Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Gender:

Female

Male

Not specified

House Name / Number

Street Name:

Postcode:

Preferred Phone Number:

Alternative Phone Number:

Email Address *

Any responses we send will go to this email address.

If you are human, leave this field blank.

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

Get directions

0161 272 5656

About the surgery

Register with the surgery

Sick (fit) notes

Feedback and complaints

© Silicon Practice

Accessibility statement

Website policies