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Change of Address

If you change your name, address or telephone number, please let us know. You can do this with the online form below.

If you move outside the Practice area, it will be necessary for you to find a Doctor in your new area.

If you are moving temporarily out of our practice area, you must sign on with a GP in your new area. We will be unable to provide medical services to you until you return to our practice area.

Please note: if you are under the care of a hospital when you change address, it is your responsibility to let them know that your details have changed.

 

1 Previous Details

Including Title
This will allow us to locate you quickly on our Patient Database.

2 Previous Address

3 Previous Contact Details

4 New Details

Provide details where different to previous.
Including Title
Please provide in the format dd/mm/yyyy
This will allow us to locate you quickly on our Patient Database.

5 New Address

6 New Contact Details

7 Education

8Additional Family Members

Family Member 1
Please provide in the format dd/mm/yyyy
Family Member 2
Please provide in the format dd/mm/yyyy
Family Member 3
Please provide in the format dd/mm/yyyy
Family Member 4
Please provide in the format dd/mm/yyyy
Family Member 5
Please provide in the format dd/mm/yyyy

9 Hospital Referrals

10 Privacy


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 known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

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.


Your Neighbourhood Professionals. Just a Click Away! BMI The Clementine Churchill Hospital
36 Northwick Park Road, Harrow, Middlesex, HA1 2NU
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Your Neighbourhood Professionals. Just a Click Away! BMI The Clementine Churchill Hospital
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