Burnham Medical Centre

BURNHAM MEDICAL CENTRE

CHANGE OF NAME FORM

This form should be used to update your medical records when you have had a legal change of name.

Please let us have sight of the legal document (i.e. marriage certificate) when passing in this form to Reception. Your document will be photocopied and returned to you.

Name: / Date of Birth:
New legal name:

If you have not changed your name legally but wish to be known by another first name, we can enter this on your medical records. You will continue to be registered under your legal name but our computer system will also access your records via the name you wish to be know by (your‘calling name’)

Full Name: / Date of Birth:
Calling name (first name only):

BURNHAM MEDICAL CENTRE

CHANGE OF NAME FORM

This form should be used to update your medical records when you have had a legal change of name.

Please let us have sight of the legal document (i.e. marriage certificate) when passing in this form to Reception. Your document will be photocopied and returned to you.

Name: / Date of Birth:
New legal name:

Full Name: / Date of Birth:
Calling name (first name only):

BURNHAM MEDICAL CENTRE

CHANGE OF NAME FORM

This form should be used to update your medical records when you have had a legal change of name.

Please let us have sight of the legal document (i.e. marriage certificate) when passing in this form to Reception. Your document will be photocopied and returned to you.

Name: / Date of Birth:
New legal name:

Full Name: / Date of Birth:
Calling name (first name only):