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Change of Contact Details

It is very important that you inform us of any changes. If you change your name we will require proof of this. We also require you to let us know as soon as possible any change of address and any new telephone numbers.

We do need to know how to contact you. Our records clerk may remove you from the list if we do not have your correct address, etc.

Documentary Proof

We will require proof of name or address changes so please bring this with you on your next visit to the practice.

1 Previous Details

Including Title
This will allow us to locate you quickly on our Patient Database.

2 Previous Address

3 Previous Contact Details

4 New Details

Provide details where different to previous.
Including Title
Please provide in the format dd/mm/yyyy
This will allow us to locate you quickly on our Patient Database.

5 New Address

6 New Contact Details

7 Education

8Additional Family Members

Family Member 1
Please provide in the format dd/mm/yyyy
Family Member 2
Please provide in the format dd/mm/yyyy
Family Member 3
Please provide in the format dd/mm/yyyy
Family Member 4
Please provide in the format dd/mm/yyyy
Family Member 5
Please provide in the format dd/mm/yyyy

9 Hospital Referrals

10 Privacy


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 known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

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.


Your Neighbourhood Professionals. Just a Click Away! New Life Clinic
212 Richmond Road , Kingston upon Thames , Surrey , KT2 5HF
  • Telephone 020 8546 3136 (Appointments/Results)
Website supplied by Oldroyd Publishing Group
Your Neighbourhood Professionals. Just a Click Away! New Life Clinic
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