Change Personal Details

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.

We will require identification (this should be photographic, such as a passport or a Photo Driving Licence) which can be attached to this form.

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).

Change of name or address

Change of name or address

If you are human, leave this field blank.

Registered practice: *

Please select... Horizon Healthcare St Thomas Road Surgery

Section

If you have a preferred pronoun, please specify:

ie. He/Him, She/Her, They/Them

Please select the information you are wanting to update?

Name

Address

Contact Numbers

Change of Name

Previous Surname: *

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).

How do you wish to be known? *

Dr

Mr

Mrs

Miss

Ms

Other

Other:

Change of Address

New address, including postcode: *

Previous address:

Please list all family members moving with you:

Only if they are registered at this practice.

Update Contact Numbers

Would you have any objection to being reminded by text for appointments?

Yes

No

New telephone number:

Please upload any relevant documents for your change of name or address:

Drop a file here or click to upload Choose File

Maximum upload size: 20.97MB