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Full Name
*
Phone Number
*
Date of Birth
Please use format day/month/year e.g. 12/05/1979
Email
*
Date of Appointment
Who is your appointment with?
Privacy Policy
This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our
Privacy Policy
to discover how we protect and manage your submitted data.
*
I consent to the practice collecting and storing my data from this form.
If you are human, leave this field blank.
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