Update Your Title / Name Current Name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last New Name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Address Street Address City State / Province / Region ZIP / Postal Code PhoneDate of Birth DD slash MM slash YYYY Please upload a picture of your marriage certificate or deed poll.Max. file size: 1 GB.ConsentTHIS 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.