The Wiggly Demo Surgery -

Change of Address Form

This is a page pre-configured for your patients to inform you of a change of address or telephone number. It is up to the surgery to display any applicable practice policy or special instructions here.

There is no extra charge for using these online patient services!

Title: Mr Mrs Miss Ms

Surname: *
Previous Surname:
Firstname(s): *
Place of birth:
Date of Birth: Format: dd/mm/yyyy *
E-mail address: *
Repeat E-mail address: *
Current Telephone:
Current Mobile number:

I am NOT a student

I am a student at:

Previous Address

Old House name/number:
Old Street:
Old Town:
Old City:
Old County:
Old Postcode:
New Address

House name/number
Street:
Town:
City:
County:
Postcode:

Other members of your family requiring a change of address (if registered here)

Name: Date of Birth:

Enter the characters as seen on the image above (case insensitive):

Code:

The completed form will be sent to an e-mail address specified by the practice.