Change of Address

Before submitting this form please check to make sure your new address fall within our practice boundary. If not you will need to register with a new surgery. Please let us know as soon as possible once you have changed your address, it is important that we have up to date contact details in case we need to contact you.

Patient Details

Name *

Date of Birth *

Contact Telephone Number *

Old Address

Old Address (inc. post code) *

New Address

New Address (inc. post code) *

Additional Household Members

Please include all family members who have also moved to the new address with you.

Have other family members moved to the new address with you? *

Yes No

If yes, please list their names and date of birth in the box below

This form collects your name, date of birth, address, and other personal information. 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

The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.

I confirm the information I’ve given is correct and I understand how it will be used

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Page last reviewed: 02 September 2022
Page created: 05 October 2026

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Change of Address

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