Change of Address

Please check your new postcode to ensure your new address is in Whiteacres Catchment Area. If your new postcode is outside the catchment area you may need to register with an alternative practice.

Please note: we will reach out if we need to check / verify any of the information you submit.

Patient Details

Title

First Name

Middle Name (if any)

Surname

NHS Number (If known)

Date of Birth

Landline

Mobile

Current Address details

Address Line 1

Address Line 2

Town / City

Postcode

New Address Details

Address Line 1

Address Line 2

Town / City

Postcode

Landline (If different to above)

Mobile (If different to above)

Email (If different to above)

Date moving / moved

Family Member 1

Title

First Name

Middle Name (If any)

Surname

NHS Number (If known)

Date of Birth

Landline

Mobile

Family Member 2

Title

First Name

Middle Name (If any)

Surname

NHS Number (If known)

Date of Birth

Landline

Mobile

Family Member 3

TitleMr, Mrs, Ms, Dr, Prof etc

First Name

Middle Name (If any)

Surname

NHS Number (If known)

Date of Birth

Landline

Mobile

Family Member 4

Title

First Name

Middle Name (If any)

Surname

NHS Number (If known)

Date of Birth

Landline

Mobile

Family Member 5

Title

First Name

Middle Name (If any)

Surname

NHS Number (If known)

Date of Birth

Landline

Mobile

Please Note:

If you have not heard back from us after 5 working days please contact the surgery to confirm your submission has been received.

Email Confirmation

Tick the box if you would like to receive an e-mail confirming the form has been received by Whiteacres Medical Centre.

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 Whiteacres Medical Centre • Maple Road, Malvern, WR14 1GQ.

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.