Change of Personal Details

Before submitting this form please check to make sure that your new address falls within our practice boundary. If not, you can still register at our surgery, but there maybe restrictions on the service that you receive.

Please let us know as soon as possible if you change your address, telephone number or name. It is important that we have up to date contact details in case we need to contact you.

Please note: If your name has changed due to Marriage or by Deed Poll, can you please provide us with a copy of the appropriate document (requirement of Department of Health).

Last Updated: 12/11/2024

Current Details

These are the details that we currently have on our clinical system for you.

Full Name *

Date of Birth *

Your Mobile Number *

Change of Name - Complete this section only if your name has changed

These are your new details - What you want to appear on your records.

*PLEASE NOTE: YOU WILL NEED TO PROVIDE LEGAL DOCUMENTATION OF YOUR NAME CHANGE.

How do you wish to be known

New Full Name

Reason for Name Change

Change of Address - Complete this section only if your address has changed

Where have you moved to?

New Address, Including Postcode

Previous Address, Including Postcode

Please list all family members moving with you

Change of Contact Details - Complete only the contact details that have changed

To update your phone number or email address, we'll send a verification link to your current number. If you no longer have access to this number, you'll need to verify your identity in person with a valid ID

New Mobile Number

Do you still have access to your old mobile number?

Yes

New Landline Number

New Email Address

Do you still have access to your old email

Yes

Declarations

Please note: If you no longer have access to your previous contact details, you will need to provide ID verification in person at the surgery

I confirm that the information provided is correct and I will provide any necessary documentation to support these changes.

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form.

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Change of Personal Details

Further Information

Connect With Us