Riverside Family Practice		
Dr N Nadeem
Dr H Akhtar	St Peter’s Centre, 
Church Street
Burnley  BB11 2DL
Tel:  01282 644123
Fax: 01282 644121	

Change of Personal Details Form

Patient Full Name	

Patient D.O.B		

NHS No.	

Currently Registered Address	

Please complete only the sections which are changing.

Name 	

New Address	

Telephone	

Mobile	

Work	

Email	

Children aged 16 or over will be required to complete their own form.
Parents/guardians of children under 16 may sign on behalf of their children.

Signed ______________________________________________

Print Name ___________________________________________

Relationship to Patient _________________________________

Date ________________________________________________