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: 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.

Title

Full Name (inc. middle):

Date of Birth (DD/MM/YYYY):

NHS or Patient Number?If known

Your Address

Address:

Postcode:

Your Contact Details

Email Address:

Home Phone Number:

Mobile Phone Number:

Physical Measurements

Your HeightPlease state whether in centimetres or feet & inches

Your Weight:Please state whether kg or stones & lbs

Lifestyle Choices

What is your current smoking status?

How many units of alcohol do you consume per week?

Additional Information

Are you a carer?

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.

I consent to my information being used for the purposes described above and wish to submit this online form to Clarendon Lodge Medical Practice • Clarendon Lodge, 16 Clarendon Street, Leamington Spa, Warwickshire, CV32 5SS.

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.