Diabetes health and wellbeing registration form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of birth *Which GP surgery are you registered with? *Select your surgery…Blackheath Medical CentreCavendish Medical CentreChurch Road Medical PracticeEarlston & Seabank Medical CentreEgremont Medical CentreGladstone Medical CentreGrove Road SurgeryHolmlands Medical CentreKings Lane Medical PracticeLeasowe Medical PracticeMiriam Medical CentreSomerville Medical CentreSt George's Medical CentreSt Hilary Group PracticeTeehey Lane SurgeryVittoria Medical Centre (Dr Majeed & Partners)Vittoria Medical Centre (Dr Karyampudi)Do you have a current diagnosis of type 2 diabetes? *YesNo surgery you? How How can we contact you? *TelephoneEmailTelephone *Email *Submit registration