Update your Details - Bank House Surgery

Change Your Contact Details

Tell us 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.

Present First Name

Present Surname

Date of Birth

Please tell us what you would like to change

Name

Address

Contact Numbers

Email Address

Change of Address

Contact Numbers

Update Email Address

Next of Kin

Full Name

Relationship to you

Contact Number

Do you give us permission to discuss your medical records with them?

Yes

I consent to the practice collecting and storing my data from this form.

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. The internet is not a secure place, however, we have gone to great steps in making sure the information you submit to us is as secure as possible. We use SSL (Secure Socket Layer) certificates to encrypt the communication between your computer and our web server. If you are not completely happy to provide information via the internet please contact the practice directly.

Email Optional

This field is for validation purposes and should be left unchanged.

Change Your Contact Details

Change of Name

Change of Address

Contact Numbers

Update Email Address

Next of Kin