Reception: Update Clinical Record

Please help us to keep our clinical records up to date by providing the information below.

You may find the link below useful in completing certain aspects of the form

https://www.nhs.uk/live-well/alcohol-support/calculating-alcohol-units/

Please do not write any clinical information on this form. Any clinical information or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 331401. We will start to process your form by the next working day and amend your records accordingly. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

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Reception: Update Clinical Record
If known
Your Address
Your Contact Details
Physical Measurements
Please state whether in centimetres or feet & inches
Please state whether kg or stones & lbs
Lifestyle Choices
Additional Information

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.

Information submitted through all secure forms, with the exception of the Leamington Primary Care Network Coil insertion/replacement form and Implant insertion/replacement/removal form, is secured with a private key and is accessed over a secure connection by nominated staff. Information submitted through the Leamington Primary Care Network Coil insertion/replacement form and Implant insertion/replacement/removal form is sent to The Leamington Primary Care Network via secure email.

We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 365 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.