Dunchurch Surgery

Change of Address

Please note that as of 1st January 2014 you will no longer be able to order repeat prescriptions via the current facility.

We have set up an alternative online system to both order repeat prescriptions and to book or cancel appointments.

Please contact reception for further information.

2 Previous Address

Previous Address

Previous Postcode

3 Previous Contact Details

E-mail Address

Home Phone Number

Mobile Phone Number

8Additional Family Members

Family Member 1

Name

Date of BirthPlease provide in the format dd/mm/yyyy

Family Member 2

Name

Date of BirthPlease provide in the format dd/mm/yyyy

Family Member 3

Name

Date of BirthPlease provide in the format dd/mm/yyyy

Family Member 4

Name

Date of BirthPlease provide in the format dd/mm/yyyy

Family Member 5

Name

Date of BirthPlease provide in the format dd/mm/yyyy

Add Family Member

10 Privacy

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

Although sending information across the Internet means that privacy of data cannot be absolutely guaranteed, our online forms offer high levels of security. The forms use HTTPS and TLS (using a 2048 bit certificate) to encrypt data sent to and from your computer when using the site and our server environment is PCI DSS certified - the highest standard of security associated with e-commerce and online finance solutions.

Form submissions are stored on the server for 28 days and are encrypted and secured with a private key known only by the GP Practice.

Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.