Village Health Group Change of Personal Details Form

Before submitting this form please check to make sure your new address falls within our practice boundary. If it does not, you will need to register with a new surgery. 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), this type of change cannot be made using the online form.

Last Updated: 24/09/2020

Your Details

Please select the current GP branch you are registered with *

East Leake

Keyworth

Ruddington (Church House)

Sutton Bonington

Surname *

Forename *

Date of Birth *

Email Address *

Change of Address

New Address, Including Postcode

Previous Address, Including Postcode

Please list all family members moving with you and their date of birth (please use their full names, also please note they may be contacted separately to verify their ID and change of details)

Update Contact Numbers

Do you consent to being reminded by text for appointments? *

Yes No

Signed: *

Dated: *

New Number Type (your preferred contact number) *

Preferred New Number (please state the number and which patient this number belongs to if there is more than one person in the household changing details) *

Second Contact Number Type

Home Number

Mobile Number

Work Number

Alternative Number

Second Contact Number

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.

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Village Health Group Change of Personal Details Form

Further Information