Skip to content
Tel: 020 7232 2243
Out of hours: 111
Log in to Patient Access
My NHS Account
Park Medical Centre
Menu
Menu
Home
Start for Life Southwark
About Us
NHS South East London Integrated Care Board
Contact
Have your Say
Making the most of your Practice
Meet the Team
Clinicians
Nurses
Practice Team
Practice Policies
At the Practice
Medical Examiner Information
Data
Patient Record
Patient Rights
Website Policies
ADHD Referrals & Shared Care Prescribing
Regulations & Governance
Young patients Friendly
Clinics & Services
Appointments, Tests & Referrals
Appointments
Self Referrals
Pharmacy First Scheme Southwark
See a Doctor or Healthcare Professional
Tests & Investigations
Clinics
How to do Clinical Test Samples
Bacterial Stool Test
FIT Test – Stool Blood Sample
Vaginal Swab – Sexual Infections
Vaginal Swab – General Bacterial test
Paediatric Urine Collection Kit
Clinical Information
Changing Statin
Sick Day Rules
Self-care
Travel Clinic & Holiday Vaccinations
Online Services
Patient Record
Learn My Way
Patient Access
NHS App
Get U Better App
Accessing full GP-held records
Practice Services
Forms
Keep us up to Date
Health Review Forms
Help & Support
News
Park Medical Centre
Menu
Home
Start for Life Southwark
About Us
NHS South East London Integrated Care Board
Contact
Have your Say
Making the most of your Practice
Meet the Team
Clinicians
Nurses
Practice Team
Practice Policies
At the Practice
Medical Examiner Information
Data
Patient Record
Patient Rights
Website Policies
ADHD Referrals & Shared Care Prescribing
Regulations & Governance
Young patients Friendly
Clinics & Services
Appointments, Tests & Referrals
Appointments
Self Referrals
Pharmacy First Scheme Southwark
See a Doctor or Healthcare Professional
Tests & Investigations
Clinics
How to do Clinical Test Samples
Bacterial Stool Test
FIT Test – Stool Blood Sample
Vaginal Swab – Sexual Infections
Vaginal Swab – General Bacterial test
Paediatric Urine Collection Kit
Clinical Information
Changing Statin
Sick Day Rules
Self-care
Travel Clinic & Holiday Vaccinations
Online Services
Patient Record
Learn My Way
Patient Access
NHS App
Get U Better App
Accessing full GP-held records
Practice Services
Forms
Keep us up to Date
Health Review Forms
Help & Support
News
Need help with a non-urgent medical or admin request? Contact us online.
Contact us online
Home
Forms
Keep us up to Date
Change of Contact Details Form
Change of Contact Details Form
Change of Personal Details
First Name
*
Present Last Name
*
Email
*
Date of birth
*
Please use format day/month/year e.g. 12/05/1979
I wish to inform the practice of:
*
Change of Name
Change of Address
Change of Phone Number
Change of Email Address
Change of Name
Previous Last Name
*
If your name changed due to Marriage or by Deed Poll please provide the practice with a copy of the appropriate documentation
How do you wish to be known?
*
Dr
Mr
Mrs
Miss
Ms
Other
Other
Change of Address
New address, including postcode
*
Previous address, including postcode
List any other family members, listed with the practice, moving with you
New Phone Number
New phone number
*
May we use this number to contact you by text with appointment reminders?
Yes
No
Privacy Policy
This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our
Privacy Policy
to discover how we protect and manage your submitted data.
Your consent
*
I consent to the practice collecting and storing my data from this form.
reCAPTCHA
Send
Close
Home
Start for Life Southwark
About Us
NHS South East London Integrated Care Board
Contact
Have your Say
Making the most of your Practice
Meet the Team
Clinicians
Nurses
Practice Team
Practice Policies
At the Practice
Medical Examiner Information
Data
Patient Record
Patient Rights
Website Policies
ADHD Referrals & Shared Care Prescribing
Regulations & Governance
Young patients Friendly
Clinics & Services
Appointments, Tests & Referrals
Appointments
Self Referrals
Pharmacy First Scheme Southwark
See a Doctor or Healthcare Professional
Tests & Investigations
Clinics
How to do Clinical Test Samples
Bacterial Stool Test
FIT Test – Stool Blood Sample
Vaginal Swab – Sexual Infections
Vaginal Swab – General Bacterial test
Paediatric Urine Collection Kit
Clinical Information
Changing Statin
Sick Day Rules
Self-care
Travel Clinic & Holiday Vaccinations
Online Services
Patient Record
Learn My Way
Patient Access
NHS App
Get U Better App
Accessing full GP-held records
Practice Services
Forms
Keep us up to Date
Health Review Forms
Help & Support
News