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Confirmation of Address

Dear Patient,

You will have received a letter or text message from us requesting you to confirm your address that we hold for you.

The reason for this is because we may have not seen you for a number of years, and / or we have received a 'return to sender' notification to a letter we have sent you in the post, or the health authority is querying your address and we need further confirmation to avoid them removing you from our practice list.

We need you to confirm your address within 2 weeks of receiving the notification, failure to do so would mean we will remove you from our practice list.

If we remove you from our list, you can re-register with us, but we would need you to confirm your address by providing proof that is dated within the last 3 months, such as a utlity, council tax bill letter, or drivers licence.

Thank you

Personal Details
Please double check you've entered the correct email address
UK Mobile only
Current Address Details
Please provide your full OLD address details
Are You In Our Catchment Area?

If you have said NO - please use the map above and check - you will not be able to submit this form without checking your address above. Once you have checked, please say YES to this question

Providing Proof

As we need you to confirm your address, we need you to provide proof of address, such as a utlity bill, council tax bill or a drivers licence (one which shows your name and full address).

Please do not send bank statements via this method.

Note: All proof received will be deleted securely upon confirmation.

Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Anyone else?
Only for those that are registered with us
If you do not have consent, please get them to submit a change of address form
Who is completing this form?
Today's date

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.


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