Change of Contact Details

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Change your personal Details

Changing your personal details

Change of address

Change of name

  • You will need to upload proof that you have changed your name. This could be a scan or photo of your marriage or civil partnership certificate, deed poll or birth certificate. 

You can also change your:

  • Smoking Status
  • Communication Concent
  • Contact details
  • Ethnicity
  • Veteran Status

All questions marked with a * are mandatory

Personal Details
If you are changing your name, this would be the name we current have for you
Please double check you've entered the correct email address and you have used your current email address
May be used to identify you
I wish to inform the practice of: *
Change of Name
Has your name changed due to Marriage or by Deed Poll: *
How do you wish to be known?:

Please upload a copy of Marraige or Deed Poll Documentation

  • You can upload a document, photo or scan
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Change of Address
Change of Phone Number
May we use this number to contact you by text: *
Which numbers(s) may we use to call you?: *
Change of Email Address
May we use this Email Address to contact you?: *
Change of Communication Consent
SMS messages:
Email messages:
Change of Smoking Status
Smoking: *
Please select all that apply: *
Have you previously smoked?: *
Are you interested in local smoking cessation services?: *
Please specify the ethnic group you consider you belong to: *
Veteran details
Please indicate which applies to you:

Privacy Consent


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