Change of Contact Details

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Changing your personal details

Change of address

If you have moved to a new address, you will need to be in our catchment area to stay registered with our surgery.
Check you are in our catchment area

Change of name

You will need to upload proof that you have changed your name. This could be a scan or photo of your marriage or civil partnership certificate, deed poll or birth certificate.

You can also change your:

Smoking Status
Communication Concent
Contact details
Ethnicity
Veteran Status

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All questions marked with a * are mandatory

Personal Details

If you are changing your name, this would be the name we current have for you

Please double check you've entered the correct email address and you have used your current email address

May be used to identify you

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I wish to inform the practice of: *

Change of Name

Has your name changed due to Marriage or by Deed Poll: *

How do you wish to be known?:

Please upload a copy of Marraige or Deed Poll Documentation

You can upload a document, photo or scan

Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx

Change of Address

Change of Phone Number

May we use this number to contact you by text: *

Which numbers(s) may we use to call you?: *

Change of Email Address

May we use this Email Address to contact you?: *

Change of Communication Consent

SMS messages:

Email messages:

Change of Smoking Status

Smoking: *

Please select all that apply: *

Have you previously smoked?: *

Are you interested in local smoking cessation services?: *

Ethnicity

Please specify the ethnic group you consider you belong to: *

Veteran details

Please indicate which applies to you:

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Privacy Consent

This form collects personal and medical information about you and we use this information to allow the practice team to contact you.
Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Change of Contact Details

Changing your personal details

Change of address

Change of name

You can also change your:

Privacy Consent

Contact

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