Hockley Medical Practice

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Tel: 0121 554 1757
Out of hours: 111

Change of Personal Details Form

Hockley Medical Practice > Managing Your Health > Change of Personal Details Form

Changing address, name, phone number or email address. Please keep us update by downloding, completing and delivering our form or by completing the online form below.

Change of name or address form

Change of Personal Details

First Name *

Present Last Name *

Email *

Enter Email

Confirm Email *

Confirm Email

Date of birth *

Please use format day/month/year e.g. 12/05/1979

I wish to inform the practice of: *

Change of Name

Change of Address

Change of Phone Number

Change of Email Address

Change of Name

Previous Last Name *

If your name changed due to Marriage or by Deed Poll please provide the practice with a copy of the appropriate documentation

How do you wish to be known? *

Dr

Mr

Mrs

Miss

Ms

OtherOther

Change of Address

New address, including postcode *

Previous address, including postcode

List any other family members, listed with the practice, moving with you

Is your new address outside the surgery’s catchment area? *

Yes

No

*

I understand I may be asked to register with another GP closer to my home addres

*

I understand I may not receive home visits from the GP surgery and community teams including: District Nurses, Community Matrons and Health Visitors.

Why do you wish to remain on the surgery list when moving out of the surgery catchment area? *

Please provide proof of address & photo ID.

Maximum upload size: 5MB

Children in the same family also changing address

Full Name

Date of birth

Please use format day/month/year e.g. 12/05/1979

Add Child Remove

New Phone Number

New phone number *

May we use this number to contact you by text with appointment reminders?

Yes

No

Privacy Policy

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.