Notification Changes

E Mail Reliability & Confidentiality

Please understand this form will be transmitted by E Mail. E Mail is never guaranteed to be reliable and totally confidential- it will pass through our ISP's computers, for instance.

If you prefer not to use E Mail, please simply come to the hatch and collect a form

First, some basic information we need to identify which record to make the changes to:-

Family Name we currently have for you (Necessary)

First Name(s)   (Necessary)

Date of Birth (in form dd/mm/yyyy)   (Necessary)

In order to minimise possibilities of abuse of this On line serve, we need your E Mail address to whom we can send a brief acknowledgement reply. This MUST be in a person identifiable form eg. jimsmith@hotmail.com, NOT anonymous@hotmail.com.

E Mail to whom we can reply (necessary)

I confirm that I am the person named above or that I am authorised by them to make changes on their behalf                      Yes     No(necessary)

Now, tell us about your new:

name title address phone number mobile phone number

E Mail address

changes in smoking alcohol consumption  exercise job

Change of name

New Family Names (new married name, etc)

Up to choice list      Down to "Submit" button

Change of Title

New Title

Up to choice list      Down to "Submit" button

Change of address notification

House name

House street number

Street or Road

Town or Village

Post Code

Do you live over 1 mile from a chemists shop as the crow flies? Yes No

Up to choice list      Down to "Submit" button

Change of Phone Number

Home Phone number

Work Phone Number

Mobile Phone Number

Up to choice list      Down to "Submit" button

Change of E Mail address

New E Mail Address

Up to choice list      Down to "Submit" button

Lifestyle

Have you changed the amount you smoke?      Yes No

If so, new amount per day (put "Nil" if stopped- WELL DONE!!)

How much alcohol do you drink in an average week?

Up to choice list      Down to "Submit" button

How much exercise do you now take in an average week?

What is your new job? (If retired, what was your job?)

Up to choice list      Down to "Submit" button

Immunisations

Have you had any Immunisations we don't know about

eg. 1997 HIB jab & booster a year later eg. 2001 Diptheria Tetanus Booster, oral polio eg. 2002 typhoid and hepatitis A to go to India

Up to choice list      Down to "Submit" button

Is there anything else you think we should know about you that would help us to help you?

Up to choice list      Down to "Submit" button

Organ & Blood Donation

NHS Organ Donor Register

I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death.

Please fill boxes as appropriate    (necessary to check at least one)

Kidneys       Heart         Liver         Corneas

Lungs          Pancreas          Any part of my body

I do not wish to donate any part of my body

NHS Blood Donor Registration

I would like to join the NHS Blood Donor Register as someone who may be contacted and may be prepared to donate blood        Yes No (necessary)

Tick here if you've given blood in the last 3 years

Up to choice list      Down to "Submit" button

Thanks for taking the time to complete this form- the details you have supplied will help make your care more efficient.

Before proceeding, may we remind you once more of the Confidentiality Problems that E Mail poses. If you have concerns, you could print out this page now on your printer, and let us have a copy. But if you are happy to submit your details by E mail, please click on the button below to submit your form.