Change of Address/Personal Details

If you are using this form to change your name, we do require photographic evidence of when and why this was changed. We cannot action a change of name without this. Please complete the form and then send a copy of your documents to hnyicb-ery.bmgreception@nhs.net

Please select the practice location most relevant to this Online Form submission:

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.

Email Confirmation

Tick the box if you would like to receive an e-mail confirming the form has been received by Bartholomew Medical Group.

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 Main Surgery • Goole Health Centre, Woodland Avenue, Goole, DN14 6RU.

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.