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Change of Surname

Please complete this form if you have changed your surname and would like us to update your medical record.

Change of Surname
Name we currently have on your medical record
New Surname that we will update your record with

Please can you email photographic evidence (i.e. marriage certificate/deed poll certificate etc.) to for this to be actioned.

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 and is accessed over a secure connection by nominated staff. We have 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.

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