Update Clinical Record

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

Your Details

Title

First Name

Surname

Date of Birth

Are you able to provide your NHS or Patient Number?

NHS Number

Marital Status

Occupation

Your Contact Details

Address

Postcode

Email address

Home Phone Number

Mobile Phone Number

Do you consent to receiving text reminders for appointment reminders, test results?

Physical Attributes

Your Height (specify if in Feet & Inches or Centimetres)

Your Weight (specify if in Pounds & Ounces, Stones or Kilograms)

Waist Measurement (specify if in Inches or Centimetres)

Lifestyle Choices

Do you currently smoke?

Do you drink alcohol?

Additional Information

Are you a carer?

Are you allergic to any medications?

What is your ethnicity?

What is your first language?

Other 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.

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 Latchford Medical Centre • 5 Thelwall Lane, Latchford, Warrington , WA4 1LJ.

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.