Update Your Address Update Your Address Name First Last Date of Birth MM slash DD slash YYYY Contact Phone NumberCurrent Address Street Address City State / Province / Region ZIP / Postal Code New Address Street Address City State / Province / Region ZIP / Postal Code Do other people that live with you who are also registered at The Lodge Surgery need to have their address updated? Yes No Please tell us their names. OptionalConsentTHIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. I consent to the practice collecting and storing my data from this form.