Change of Address Form

It is important we hold complete and up-to-date information so we can provide the best level of care possible. You will need to complete a Change of Address Form for each member of your household; this is to ensure we correctly update all patients’ details. As your GP we treat confidentiality very seriously and will never share your information with any other organisation without your prior consent.

Please select the practice location most relevant to this Online Form submission:

First Name

Surname

Date of Birth

Faith

New Address

Post Code

Home Telephone

Mobile Telephone *

* We will use your mobile phone to provide you with Health Service Information, including Public Health Screening Information via SMS. You can opt out at any time, please contact us if you wish to do so. Please note: we will in your Vital interests

Do you wish to opt out of receiving SMS messages?

Preferred method of communication

We will attempt to make contact with you using your preferred method of communication – however, please note, we will attempt to make contact using all means in order to ensure you receive safe and effective care.

Do you give consent, if necessary for us to leave an answerphone message:

Submission of a form is not confirmation that you can stay registered with the surgery. If you have moved outside of the practice boundary, you may be asked to register at a surgery closer to your new address.

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 and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Buckshaw Village Surgery (BVS) • Buckshaw Village Health Centre, Unity Place, Buckshaw Village, Chorley, PR7 7HZ.

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.