290 Knowsley Road, Bootle, Merseyside, L20 5DQ
Tel: 0151 922 3841
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Change of Contact Details
Your Details
Title: *
First Name(s): *
Date of Birth: *
NHS No: *
Surname: *
Previous surname: *
Sex: Male Females
Date of Change: *
Old Address and Telephone: *
Postcode: *
Home Tel: *
New Address and Telephone: *
Postcode: *
Home Tel: *
Mobile: *
Work Tel: *
Email: *
Confirm Email: *
Note: If your new address falls outside of our catchment area, you will need to register with a new GP and we will be contacting you regarding this matter.
Are you a student?
     I AM a student at:
Other members of your family requiring a change of address (if registered here)
Practice staff other than the doctor or nurse will read this:
Name: Date of Birth:
Name: Date of Birth:
Name: Date of Birth:
Name: Date of Birth:
   
 
About This Form
Fields marked with a red asterisk are compulsory.*
 
Documentary Proof
We will require proof of name or address changes so please bring this with you on your next visit to the practice
 
Confidentiality
By using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy.
Also, by sending this form you are indicating your agreement that the surgery may contact you by email or telephone to discuss the information contained in this form.
If either of these points concerns you or you disagree in any way then you should use another method of notifying us of your change of contact details.
 
Personal Information
Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential. 
 
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