Update Personal Information Smart Triage Set up Leaflet Please complete the online form below if you wish to inform the practice of a change to your address or contact details. Unfortunately we cannot accept change of name online Name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last Previous Surname OptionalDate of Birth DD slash MM slash YYYY Place of Birth OptionalEmail Enter Email Optional Confirm Email Optional Current Home Number OptionalCurrent Mobile Number OptionalWould you like to receive text message reminders? Yes No Are you a student? Yes No Where are you a student at?Previous Address Street Address Optional Address Line 2 Optional City Optional Postcode Optional Current Address Street Address Optional Address Line 2 Optional City Optional Postcode Optional Other members of your family requiring a change of address (if registered here)NameDate of Birth Add RemoveComments OptionalThis field is for validation purposes and should be left unchanged.