Change Your Contact Details Please complete the online form below if you wish to inform the practice of a change to your address or contact details. Change Your Contact Details (address) Title Mr Mrs Miss Ms Mx Dr Other Surname * Previous Surname Forename(s) * Date of Birth * Email Address Confirm Email Address Current Home Telephone Current Mobile Number Current Address * Current Address Current Address Current Address City City County County Post Code Post Code Previous Address if recently moved house Previous Address if recently moved house Previous Address if recently moved house Previous Address if recently moved house City City County County Post Code Post Code Please inform us of any other family members that need their address amending following moving address Family Member – Name Family Member – Name Family Member – Name Family Member – Name Would you like to receive text message reminders? Yes No I am a Carer I am not a Carer Carer’s Details – If you are completing this form on behalf of somebody and you are their registered carer – Please tell us your name and contact details What is your Smoking Status? * Never Smoked Ex Smoker Light Cigarette Smoker (1-9 per day) Moderate Cigarette Smoker (10-19 per day) Heavy Smoker (20-39 per day) Very Heavy Smoker (40+ per day) Electronic Cigarette User I do not want to give this information If you currently smoke, would you be interested in stopping smoking? Yes – Please send me information and help to quit smoking No – I am not interested in stopping smoking Not Applicable How many alcohol units do you consume per day? * I do not drink alcohol I only ever drink occasionally Light Drinker (1-2 units per day) Moderate Drinker (3-6 units per day) Heavy Drinker (7-9 units per day) Very Heavy Drinker (More than 9 units daily) I do not want to give this information How tall are you? * How much do you weigh? * What is your blood pressure? For example: 120/80 mmHg If you do not have a home BP machine or you do not know your blood pressure, then please come into the surgery and use our free BP machine located in reception. Please ask reception for a gold token. Text Submit If you are human, leave this field blank.
