Changing your contact details

To update details like your name, address, phone numbers or email address:

fill out the change of contact details form below
phone or visit the surgery, when we are open

Change of address

Please inform us of a change of address immediately. Failure to do so, could result in your name being removed from our list because you can’t be traced via correspondence. The practice will be unable to prevent this action taking place.

Remember, patients with hospital referrals must also contact the hospital, to inform them of the change of address.

Changing your phone number or email address

If your house phone, mobile number, or email address changes, please let us know as soon as possible.

Changing your date of birth or name

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

Use this form to update the contact details for you and your family:

Your details

NHS number

Get help to find your NHS number online

Title(Required)

Mrs

Miss

Other

Name(Required)

First Last

Date of birth(Required)

Day

Month

Year

Sex(Required)

Male

Female

Which details would you like to change today?(Required)

Your address

Your home telephone number

Your mobile number

Your email address

Your ethnic group/background

Your address details

Please provide your previous address and your new address details in the boxes below

Previous address

Previous postcode

Your new address

Your new postcode

Home telephone number

Please provide your old and new home telephone numbers in the boxes below.

Old home telephone number

New home telephone number

Mobile telephone number

Please provide your old mobile number (if known) and your new mobile number in the boxes below

Old mobile telephone number (if known)

New mobile telephone number

Your email address

Old email address

Enter Email Confirm Email

New email address

Enter Email Confirm Email

Your ethnicity

Your ethnic group/background

White - British

White - Irish

White - Irish Traveller

White - Traveller

White - Gypsy/Romany

White - Polish

Any other white background

Mixed - White and Black Caribbean

Mixed - White and Black African

Mixed - White and Asian

Any other Mixed background

Asian or Asian British - Indian

Asian or Asian British - Pakistani

Asian or Asian British - Bangladeshi

Any other Asian background

Black or Black British - Caribbean

Black or Black British - African

Black or Black British - Somali

Black or Black British - Nigerian

Any other Black background

Other ethnic group - Chinese

Other ethnic group - Filipino

Any other ethnic group - Chinese

Not stated*

*Not stated should be used where you have been given the opportunity to state your ethnic category but choose not to

Please state your ethnic group or background

Other members of your family

Do you need to change the details for any other members of your household who are registered with this practice?(Required)

Yes

Name 1(Required)

First Last

Date of birth 1(Required)

Day

Month

Year

Please state ethnic group or background 1(Required)

Name 1 - Is this person an adult (over the age of 16 years)?(Required)

Yes

Name 1 - Please enter their email address (if different from above)

Enter Email Confirm Email

Name 1 - Please enter their mobile number (if different from above)

Do you need add another family member (2)?

Yes

Name 2(Required)

First Last

Date of birth 2(Required)

Day

Month

Year

Please state ethnic group or background 2(Required)

Name 2 - Is this person an adult (over the age of 16 years)?(Required)

Yes

Name 2 - Please enter their email address (if different from above)

Enter Email Confirm Email

Name 2 - Please enter their mobile number (if different from above)

Do you need to add another family member (3)?

Yes

Name 3(Required)

First Last

Date of birth 3(Required)

Day

Month

Year

Please state ethnic group or background 3(Required)

Name 3 - Is this person an adult (over the age of 16 years)?(Required)

Yes

Name 3 - Please enter their email address (if different from above)

Enter Email Confirm Email

Name 3 - Please enter their mobile number (if different from above)

Do you need to add further family members (4)?

Yes

Additional family members

If you need to add further family members to this form please use the space below to add their full name and date of birth and any changes you would like to report.

Do you consent to receive SMS text messages from the practice?(Required)

Yes

Do you consent to receive emails from the practice?(Required)

Yes

Not for urgent medical help(Required)

Yes, I understand this form is NOT for urgent medical help

Consent(Required)

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.

I agree to the privacy policy.

Change of address

Changing your phone number or email address

Changing your date of birth or name

Your details

Your address details

Home telephone number

Mobile telephone number

Your email address

Your ethnicity

Other members of your family

Policy

Helpful links

Clare Road Medical Centre