Change of details

Please help us to keep our clinical records up to date by providing the information below.

Please note this is not for change of name – download the Change of Details form (DOCX, 16KB) and bring it to reception with the required ID. All name changes will require evidence to be produced to reception eg. Marriage certificate, name change by deed poll. Only originals will be accepted.

If you are changing your address and it is still within our boundary (this can be checked by going to area map page, where there is a boundary checker.

You will still need to supply a council tax bill or tenants agreement in the new address, for us to update your details.

You can contact our Admin department by going to Patient Triage , let us know that you have changed your address and submitted the form, and we can send you a link, so you can photograph the information needed.

Previous Details

Full NameIncluding Title

Can you provide your Previous NHS or Patient Number?This will allow us to locate you quickly on our Patient Database.

NHS Number

Previous Address

Previous Postcode

Previous Contact Details

E-mail Address

Home Phone Number

Mobile Phone Number

New Details

Provide details where different to previous.

New Full Name, if changedIncluding Title

Date of BirthDD/MM/YYYY

Can you provide your New NHS or Patient Number?This will allow us to locate you quickly on our Patient Database.

NHS Number

New Address

New Postcode

New Contact Details

E-mail Address

Home Phone Number

Mobile Phone Number

Education

Are you a Student?

Additional Family Members

Name of additional family member 1

Date of Birth of family member 1

Name of additional family member 2

Date of Birth of family member 2

Name of additional family member 3

Date of Birth of family member 3

Name of additional family member 4

Date of Birth of family member 4

Name of additional family member 5

Date of Birth of family member 5

Add Family Member

Hospital Referrals

Have you been referred to a Hospital?

Privacy

I agree that the surgery may contact me by e-mail or telephone to discuss the information contained in this form.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Shotfield Medical Practice • Shotfield, Wallington, Surrey, SM6 0HY.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

Residential/
Nursing Care

Counselling