Change of personal details

We often try to contact patients only to find that their telephone numbers have changed; Please use this form (see below) to notify us of any changes to your personal details, for instance a change of mobile phone number, a change of address or change of name. This will help us keep our records up to date and enable us to contact you directly should we need to do so. We are now operating a text appointment reminder service, so please ensure your contact details are kept up to date.

We have placed a quantity of slips at both surgeries for you to complete, alternatively you can email balsallcommon.practice@nhs.net or complete the online form below.

If you move outside the practice area, it will be necessary for you to find a doctor in your new area. Birmingham and Solihull CCG will help you if you experience difficulty. Advice regarding moving to a new area is on your medical card. Please read it and keep your medical card in a safe place.

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

Previous Details

Full NameIncluding Title

Can you provide your Previous NHS or Patient Number?This will allow us to locate you quickly on our Patient Database.

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.

Full NameIncluding Title

Date of BirthDD/MM/YYYY

Can you provide your New NHS or Patient Number?This will allow us to locate you quickly on our Patient Database.

NHS Number

New Address

New Postcode

New Contact Details

E-mail Address

Home Phone Number

Mobile Phone Number

Education

Are you a Student?

Additional Family Members

Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

Add Family Member

Hospital Referrals

Have you been referred to a Hospital?

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 Balsall Common Surgery • Balsall Common Health Centre, 1 Ashley Drive, Balsall Common, Coventry, West Midlands, CV7 7RW.

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.