Change of Details

This form is for non-urgent/non-clinical questions, and it may take 2 working days for the reception team to reply. If you are unwell please call the practice - Gallions Reach Health Centre 020 8333-5000 / Heronsgate Medical Centre 020 8333-5050

Please select the practice location most relevant to this Online Form submission:

Change of Details

Full Name

Date of Birth

Can you provide your Previous NHS or Patient Number?

NHS Number

Previous Address

Previous Postcode

Previous Contact Details

E-mail Address

Home Phone Number

Mobile Phone Number

New Details

Provide details where different to previous.

New Address

New Postcode

New Contact Details

E-mail Address

Home Phone Number

Mobile Phone Number

Additional Family Members

Family Member 1 Name

Family Member 1 Date of Birth

Family Member 2 Name

Family Member 2 Date of Birth

Family Member 3 Name

Family Member 3 Date of Birth

Family Member 4 Name

Family Member 4 Date of Birth

Privacy

I agree that the surgery may contact me by e-mail or telephone to discuss the information contained in this form.

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.

I consent to my information being used for the purposes described above and wish to submit this online form to Gallions Reach Health Centre • Bentham Road, London, SE28 8BE.

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.