Update Your Contact Details

It’s important that we always have your correct personal details so we can reach you about your care. If your phone number, email address, home address, next of kin or name has changed, please use this form to let us know.

When you submit the form, our practice team will verify the information and update your record in our clinical system. For changes to your name (e.g. through marriage or deed poll), we may contact you to request supporting documentation such as a marriage certificate.

Keeping your record up to date helps ensure appointment reminders, test results, and other important information reach you safely.

Your details (for verification)

Full Name(Required)

(As currently registered)

First Middle Last

Date of birth(Required)

Address (As currently registered)(Required)

Address Line 1 Address Line 2 Village/Town/City County Post Code

NHS number (if known)

https://www.nhs.uk/nhs-services/online-services/find-nhs-number/

Changes you want to make (leave blank if no change)

The NHS and your GP surgery can use these details to call, text or email you about health care services. All phone numbers must be registered in the UK.

New mobile/landline telephone number

New E-mail address

Would you like to receive information from The Middlewood Partnership such as a patient newsletter, surveys for improvements, info on upcoming events in the community and info on the various clinics and services that we run? The information we send would only include relevant material to our patients for the sole purpose of communication. We would not pass your email on to any third party.

I consent

I do not consent

Add/update next of kin name

Add/update next of kin mobile number

Are you happy for us to contact your next of kin in an emergency?

Yes

Alternative emergency contact name

Please provide this information if you do not want us to contact your next of kin in an emergency

Alternative emergency contact mobile number

Please provide this information if you do not want us to contact your next of kin in an emergency

New home address

Address Line 1 Address Line 2 Village/Town/City County Post Code

New name

For changes to your name (e.g. through marriage or deed poll), we may contact you to request supporting documentation such as a marriage certificate

Title First Last

If you are completing this form for somebody else

Your Name

First Last

Relationship to the patient

I confirm the information provided is correct and I am the patient or an authorised representative.

I understand the practice may contact me to verify this request and, for name changes, to request supporting documentation.