Change of Address

Please inform us of any change of address and contact details in the area below. You may be contacted by the practice to confirm the information you submit.

Change of Personal Details

If you are human, leave this field blank.

First Name

Present Last Name

Email

Enter Email

Confirm 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

OtherOther

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.

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

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Riverside Medical Practice
Musselburgh Primary Care Centre
Inveresk Road
Musselburgh
EH21 7BP

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Telephone: 0131 536 4468
Out of hours: 111

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