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Polden Medical Practice
Menu
Home
About Us
Contact
Environmental and Sustainable Performance
Have your Say
Making the most of your Practice
Meet the Team
Practice Policies
At the Practice
Data
Patient Record
Patient Rights
Website
Regulations & Governance
Teenage Friendly
Clinics & Services
Appointments, Tests & Referrals
Appointments
Know Who to Turn to for Your Healthcare
Referral for Further Care
See a Doctor or Healthcare Professional
Tests & Investigations
Clinics
Online Services
Practice Services
Your Record
Keep us up to Date
Health Review Forms
Your Data
Help & Support
Help & Support Services
Who Do I Need to See?
News
Polden Medical Practice
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Change of Contact Details Form
Change of Contact Details Form
Change of Personal Details
First Name
*
Present Last Name
*
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
Other
Other
Change of Address
New address, including postcode
*
Previous address, including postcode
List any other family members, listed with the practice, moving with you
New Phone Number
New phone number
*
May we use this number to contact you by text with appointment reminders?
Yes
No
Proof of Identification
Please provide two forms of identification, one must be photographic such as passport, bus pass, driving licence etc, the other a utility bill, or any other official document. If you are unable to provide identification please contact the Practice.
How will you provide evidence of this change?
*
Upload on this form
Deliver to the Practice
File Upload
*
Drop a file here or click to upload
Choose File
Maximum file size: 10MB
We accept jpeg, pdf, gif, tiff,doc and docx files
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.
*
I understand additional personal data is provided to the Practice, including IP location and software information.
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Environmental and Sustainable Performance
Have your Say
Making the most of your Practice
Meet the Team
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At the Practice
Data
Patient Record
Patient Rights
Website
Regulations & Governance
Teenage Friendly
Clinics & Services
Appointments, Tests & Referrals
Appointments
Know Who to Turn to for Your Healthcare
Referral for Further Care
See a Doctor or Healthcare Professional
Tests & Investigations
Clinics
Online Services
Practice Services
Your Record
Keep us up to Date
Health Review Forms
Your Data
Help & Support
Help & Support Services
Who Do I Need to See?
News