Please inform us of any change of address and contact details in the area below. You may be contacted by the practice to confirm the information you submit. If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required First Name * Last Name * Email * Date of Birth * day/month/year I wish to inform the Practice of: * Change of NameChange of AddressChange of Phone NumberChange of email Address My New Name My New Address Please note if you are outside our catchment area you may be required to register with a different practice. Address Town/City Postcode Phone Number Email 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. *