Update your personal details

Update your personal details - By sending in this form you are agreeing to receive email and/or sms communications from us. We will only use this information to communicate with you about Penicuik Medical Practice and the service we provide.

Your Old Details

Title *

Name *

Date of Birth *

Home Address *

Phone Number

Email Address *

Your New Details

Title *

Name *

Date of Birth *

Home Address

Phone Number

Email Address

Update Emergency Contact Details

Information/Notes

Any additional information/Notes

Height & Weight

Height

Weight

Waist

Blood Pressure

Resting Pulse (beats per minute)

Smoking

Do you currently smoke?

Yes No

If 'Yes', How many cigarettes do you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

Would you like us to contact you with advice on giving up smoking?

Yes No

Other Information

Are you a carer

Yes No

If 'Yes', Name of Person caring for

Date of Birth

WHAT IS YOUR RELATIONSHIP TO THE PERSON BEING CARED FOR?

IS THE PERSON YOU CARE FOR REGISTERED AT THIS SURGERY

Yes No

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

I consent to the practice collecting and storing my data from this form.

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