Update Your Details.

If you’ve changed your address, phone number, or name, you can let us know here.

Let’s keep in touch.

It’s important that we’re able to contact you, so you can help us by keeping your personal information up-to-date.

You can use the online form below to notify us of your change of details - or, if you’d rather do so in person, you can drop into the practice and pick up a paper form.

Change of Contact Details

Documentary Proof

We require proof of name or address changes, so please bring this with you on your next visit to the practice.

Confidentiality

By using this form you will be sending information about yourself across the Internet.

Also, by sending this form you are indicating your agreement that the surgery may contact you by email or telephone to discuss the information contained in this form.

If either of these points concerns you or you disagree in any way then you should use another method of notifying us of your change of contact details.

Personal Information

Personal information retained on our system is stored in a secure data centre located in the UK and is treated as confidential.

Title

First Name(s)

Last Name

Date of Birth

YYYY

NHS Number

Sex

Male

Female

Previous Surname

Date of Change

YYYY

Change of Address

Note: If your new address falls outside of our catchment area, you will need to register with a new GP and we will be contacting you regarding this matter.

Old Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

New Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Change of Phone Number

Old Home Number

New Home Number

Old Mobile Number

New Mobile Number

Are you a student?

If yes, please tell us which institution you are registered with below.

I am not a student

I am a student

School/College/University

Other members of your family requiring a change of address (if registered here)

Name

Family Member 1

Date of Birth

Family Member 1

YYYY

Name

Family Member 2

Date of Birth

Family Member 2

YYYY

Name

Family Member 3

Date of Birth

Family Member 3

YYYY

Name

Family Member 4

Date of Birth

Family Member 4

YYYY

This form collects your name, date of birth, email, other personal information and medical details which you enter. We use Squarespace as our website provider and any information you enter into this form is also processed by them in accordance with GDPR and forwarded to Elbury Moor Medical Centre's NHS email address. 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.

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