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Loose Branch Surgery

Please open patient letter for further information regarding the transfer of the Loose Branch Surgery to Greensand Health Centre

1. DRAFT Patient Letter Download

If you wish to continue visiting the Loose Road Branch Practice for your appointments; you must transfer over to Greensand Health Centre. Please complete your details below to transfer — these will go direct to Greensand Health Centre who will then contact you once you are registered with them.

Stay with Loose Road Surgery

Please confirm *

I wish to continue visiting Loose Road Branch Practice and transfer to Greensand Health Centre

First Name *

Last Name *

Email *

Enter Email

Confirm Email *

Confirm Email

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Address *

Postcode *

Additional Family Members

Please provide details of any family members who also want to remain with Loose Road Surgery

Full Name

Date of birth

Phone Number

Add another family member Remove

Privacy Policy

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.

If you are human, leave this field blank.

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