			Allesley Park Medical Centre
			2 Whitaker Road, COVENTRY, CV5 9JE


		Telephone for appointments: 024 76 674123 * Out of Hours: 01926 888 026

Change of Address

It is also important to tell us if you change address either within our catchment area or if you move away from our catchment area. Please note that you cannot continue to be registered with us if you move out of the catchment area.The Primary Care Trust regularly checks our lists and if they suspect a person is no longer resident at the address they are registered then they will remove the patient's name from our list and your medical notes have to be returned to the Primary Care Trust.

It is important that we have accurate details of your address and can contact you if we need to!

This form is not encrypted, so do not include any confidential personal or medical information. If you are unhappy about sending this information over the internet, use an alternative method - see here.

Otherwise complete the questions and press SUBMIT at the bottom of the form.

Your surname or family name*
Your first name(s)*
Previous surname(s)
Your date of birth*	in format DD-MM-YYYY e.g. 30-11-2006
Your old address*
Your old address*	Postcode*
Your new address*
Your new address*	Postcode*
Telephone number (new)
Mobile phone number
Email address*
Date of move	in format DD-MM-YYYY e.g. 30-11-2006

*= required fields