By visiting our site, you agree to our privacy policy regarding cookies, tracking statistics, etc.

Templepatrick Surgery

80 Castleton | Templepatrick | BT39 0AZ
Main Menu

Updating Your Contact Details

Changing your Contact Details with the Surgery

Please complete the form below to update your contact details with us, we can then update our records. We will require proof of name or address changes, so please bring this with you on your next visit to the practice.

Please Note: Fields marked with an * are required

Change of Address

Previous Details

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

Previous Contact Details

New Details

Provide details where different to previous
This will allow us to locate you quickly on our Patient Database.

New Contact Details

Please give details below of family members who reside with you and are registered with this Practice.

Hospital Referrals

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.

Scroll to Top
Skip to content