Change your details

First name

Last name

Enter Email

Confirm Email

Date of birth

Please use format day/month/year e.g. 12/05/1979

I’d like to let the Practice know about:

Change of name

Change of address

Change of mobile phone number

Change of home phone number

Change of email address

Change of name

Previous name

If your name changed due to Marriage or by Deed Poll please provide the practice with a copy of the appropriate documentation

New name

Change of address

New address, including postcode

Previous address, including postcode *

List any other family members registered at Riverside Medical Practice who are moving with you

New mobile phone number

Can we use this number to contact you by text with appointment reminders and information about your health, including requests for you to book any necessary review appointments? *

Yes

New email address

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.

I consent to the practice collecting and storing my data from this form.

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Change your details

Change of name

Change of address

New mobile phone number

New email address

Privacy Policy

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