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Change of Contact Details Form

Change of Personal Details
Please use format day/month/year e.g. 12/05/1979

Change of Name

Maximum file size: 10MB

If your name changed due to Marriage or by Deed Poll please provide the practice with a copy of the appropriate documentation. We accept pdf files only, up to a total upload size of 5MB. If completing this form using a smartphone or tablet download a ‘PDF Scanner’ app to take pictures of your proof of identification.

Change of Address

Maximum file size: 5MB

We will accept official documentation that includes your name and the address. If the documentation you provide is not sufficient we may contact you for further evidence.

Change of Correspondence Address

A correspondence address is an address that you can be officially contacted at but is not your main residence. Your Leicester address will remain as your address on your medical record with us

New Phone Number

New Email Address

Enter Email
Confirm Email


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.