Cookstown Health Centre

Patients should contact reception requesting to register with the practice. The receptionist will record patient details and arrange an appointment with the practice nurse fro examination and routine procedures. The practice does not discriminate on the grounds of:

You can also register online by inserting your details below.

Security note: Electronic transmissions on the Internet are not always secure and theoretically it is possible for the details emailed from this form to be intercepted by a third party. If you have any concerns, we advise you to visit the surgery and present your details in person.

- REGISTER WITH THE PRACTICE -
Full Name:
Email Address:
Home Address:
Telephone Number:
Marital Status:
Previous Surnames:
Date Of Birth:
Major Illnesses:
NHS Number (If known):
Town/Country Of Birth:
Previous Address If Any In The UK :
Name & Address Of Your Last GP:
	If You Are From Overseas Please Fill In This Section
Your First Address In The UK Where You Registered With A GP:
If Previously Resident In UK - Leaving Date:
Date You Moved To UK:
	If Returning From The UK Armed Forces Fill In This Section
Address Before Enlisting:
Service Or Personnel Number:
Enlistment Date:
Any Other Information?: