Contact Details Update Form

Title:

First Name(s):*

Surname:*

NHS No:

Date of Birth:*

Change of surname

Please complete this section only if you have changed your surname.

Previous surname:

Date of Change:

Change of address

Complete this section if you have moved. Please provide us with your old address and your new address.

Old Address:

Postcode:

New Address:

Postcode:

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.

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

Name

Date of Birth:

Name:

Date of Birth:

Name:

Date of Birth:

Change of contact details

Please complete this section to update your telephone number(s) and/or email address.

New Mobile No:

New Home No:

New Email:

Disclaimer

The information you provide in this form will be processed by Cedar Practice. The information will be treated as confidential and stored in a secure data centre located in the UK. The information will be uploaded to your record in the practice’s clinical system as soon as possible after submission, after which the copy of your information in the data centre will be securely destroyed.

Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of providing this information.

The information you provide will be processed with the sole purpose of providing you with Direct Care within the surgery and in support of Direct Care elsewhere. Our Privacy Policy provides further detail about how we process your personal information for the purposes of Direct Care.

You have the right to revoke this Consent to the terms laid here, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent.

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Name

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