Change of Contact Details Form

Current registration details

Please complete this section with the information you used to register at the practice.

Title * Title

Family Name *

Given/First Name *

Date of Birth *

Please update my Info

I would like to update the registration information the surgery holds for me on file

Changing your name

I wish to change the following

My Title

My First Name

My Calling Name

My Last Name

Your Calling Name may be a nickname you prefer to be called, rather than an actual change to your registration.

New Title *

Calling Name

New Family Name *

New Given/First Name *

Please note; you may be asked for proof if identity if you are changing your name.

Type of Accommodation

Type of Accomodation

I am staying in Student Accommodation/Hall of Residence

I live in other accommodation

Halls or Residence (by name) Halls or Residence (by name)

Do you know your Room number?

Yes, I know my Room No.

No, I do not know my Room No.

Room Number

Address Summary

Name of Hall

Room Number if known

Room Number Unconfirmed

Hall Address – Bankside

Hall Address – Butlers Wharf

Hall Address – Carr Saunders

Hall Address – High Holborn

Hall Address – Lillian Knowles House

Hall Address – Passfield

Hall Address – Rosebery

Hall Address – Sidney Webb House

Hall Address – Urbanest Kings Cross

Hall Address – Urbanest Westminster Bridge

City

Hall Postcode – Bankside

Hall Postcode – Butlers wharf

Hall Postcode – Carr Saunders

Hall Postcode – High Holborn

Hall Postcode – Lilian Knowles

Hall Postcode – Passfield

Hall Postcode – Rosebery

Hall Postcode – Sidney Webb

Hall Postcode – Urbanest Kings cross

Hall Postcode – Urbanest Westminster

Your postcode indicates you live outside the main boundary for registration at, however, you may register with us as an Out of Area Patient.

Registering at this practice as an “out of area” patient.
As you live outside the Practice area (catchment area), we are not required to provide you with home visits.
You may, on occasion, develop an urgent illness or injury at home which means that attending the GP surgery as normal would not be appropriate.
If you require a GP, please contact this practice in the first instance. If we determine you need access to services local to where you live, we may ask you to call NHS 111.
In these circumstances, NHS 111 will direct you to the local service that has been established by NHS England for patients such as you. This local service could be a GP practice near to where you live, the local walk-in or urgent care centre, A&E, or minor injuries unit.
The local services will then decide if you can attend for an urgent face-to-face appointment with a healthcare professional, or if a home visit is needed, which will be based on your individual circumstances.
If this is in the out-of-hours period when the surgery is normally closed between 8.30 and 18.30 am weekdays and during weekends – NHS 111 will direct you to the local out-of-hours provider.

Out of Area Confirmation for Halls of Residence

I confirm I would like to register as an Out of Area patient.

Home Address

First Line of Address

Second Line of Address

City/Town

Postcode

Out of Area Confirmation

I confirm I would like to register as an Out of Area patient.

Phone Contact Details

Primary Contact Telephone Number Type

Type of Number

Mobile

Home

Work

Email Contact Detail

Main Email Address

Please ensure to tell us if you change this

Type of Email Account

University Email Address

Personal Email Address

Work Email Address

Other Information to be changed

Please tell us here about any registration information you would like to change.

If you are human, leave this field blank.