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Change of Address

Please complete this form to advise us of your change of address or any other changes to your contact details.

1Change of Address

PLEASE NOTE: You will need to provide proof of your change of address. Please bring some form of proof into the surgery of your change of address.

2Previous Details

This will allow us to locate you quickly on our Patient Database.

3Previous Address

4Previous Contact Details

5New Details

Provide details where different to previous.

Please provide in the format dd/mm/yyyy

6New Address

7New Contact Details

8Education

9Additional Family Members

Please provide in the format dd/mm/yyyy
Please provide in the format dd/mm/yyyy
Please provide in the format dd/mm/yyyy
Please provide in the format dd/mm/yyyy
Please provide in the format dd/mm/yyyy

10Hospital Referrals

11Privacy

PLEASE NOTE: You will need to provide proof of your change of address. Please bring some form of proof into the surgery of your change of address.


Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.


Your Neighbourhood Professionals. Just a Click Away! Foot problems?
739 - 741 Stratford Road, Springfield, Birmingham, B11 4DG
  • Telephone 0121 778 4321 / 0121 778 4422
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Your Neighbourhood Professionals. Just a Click Away! Foot problems?
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