CHANGE OF PATIENT’S NAME AND/OR ADDRESS

PLEASE COMPLETE IN BLOCK CAPITALS

DATE:

REGISTERED GP:

SURNAME:

FORENAME:

MR/MRS/MISS/OTHER (please state)

DATE OF BIRTH:

PREVIOUS ADDRESS:

POST CODE:

PREVIOUS TELEPHONE NUMBER:

NEW ADDRESS:

POST CODE:

NEW TELEPHONE NUMBER:

WHEN DID YOU MOVE TO YOUR NEW ADDRESS?:

NEW NAME:

MEMBERS OF YOUR HOUSEHOLD, REGISTERED WITH THIS PRACTICE WHO HAVE ALSO CHANGED ADDRESS

Surname	First Name(s)	Mr/Mrs/Miss	Date of Birth
Day	Month	Year

ARE YOU OR ANY MEMBERS OF YOUR FAMILY CURRENTLY AWAITING/ATTENDING

HOSPITAL APPOINTMENTS? (If YES, please tick box)

OFFICE USE ONLY:-

DATE RECORDS CHANGED:

BY:

E-Mail Address(es) – (please state if home/work)
You
Other family members – please list below

We are currently looking into more cost effective ways of inviting patients to our clinics in the future, one of which is via e-mail.

Please let us know if you do, or do not, wish the practice to send clinic invitations to you via e-mail by completing and signing the declaration below.

This declaration will only be relevant to the signatory of this form.

I	, *do/do not agree to Woodside Medical Practice sending clinic invitations to me via my *home/work e-mail address.

Signature
Date

* Please delete as appropriate

V:\Forms\Administration Forms\CHANGE OF ADDRESS.dot

PTO

CHANGE OF PATIENT’S NAME AND/OR ADDRESS

Woodside Medical Practice

2002-10-22

NHSG

GHB