Gladstone Medical Centre

Gladstone Medical Centre

241-247 Old Chester Road Rock Ferry, Birkenhead Wirral, CH42 3TD

Current time is 05:29 - Sorry, we're currently closed. Please call NHS 111

NHS

Telephone: 0151 645 2306

wiccg.gatekeeper-n85031@nhs.net

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Online Pre-Registration

If you wish to pre-register please complete the form below. When you have completed all of the details, click on the “Send” button to mail your form to us. When you visit the surgery for the first time you will be asked to sign the form to confirm that the details are correct.

When you register you will also be asked to fill out a medical questionnaire please complete the form below. This is because it can take a considerable time for us to receive your medical records.

Online Medical Questionnaire For New Patients

Note that by sending the form you will be transmitting information about your self across the Internet and although every effort is made to keep this information secure, no guarantee can be offered in this respect.

Alternatively you may print off a registration form, fill it out and bring it in with you on your first visit to the practice.

Registration Form

 

 

 

New Patient Health Questionnaire

  • MM slash DD slash YYYY
  • Please enter parent/guardian name and relationship
  • Next of Kin

  • Alcohol Usage

    Scoring: a total of 5+ indicates hazardous or harmful drinking
  • Family History

  • Medical History

  • To be completed by females only

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