KLINIK - Update your Details

Update your Details
EMAIL USE
Are you registered with York Medical Group? *
What would you like to update? *

About you
Current First Name *
Current Surname *
Date of Birth *

Day Month Year
Gender Identity
NHS Number *
Click HERE to find out your NHS number
Ethnicity *
Which of the following options best describes how you think of yourself?

Contact Details
Address

Street Address

Street Address Line 2

City County

Post Code
Preferred Number
Mobile Number
Landline Number

Area Code Phone Number
Do you consent to receive SMS communications?

Pronouns, Title & Preferred Name
Preferred Name
Pronouns
Other Pronoun choice
Title

Type 1 Opt-out Preference
The data held in your GP medical records is shared with other healthcare professionals for the purposes of your individual care. It is also shared with other organisations to support health and care planning and research.

If you do not want your personally identifiable patient data to be shared outside of your GP practice for purposes except your own care, you can register an opt-out with your GP practice. This is known as a Type 1 Opt-out.

Type 1 Opt-outs may be discontinued in the future. If this happens then they may be turned into a National Data Opt-out. Your GP practice will tell you if this is going to happen and if you need to do anything. More information about the National Data Opt-out is here: https://www.nhs.uk/your-nhs-data-matters/

This decision will not affect individual care and you can change your choice at any time, using this form.
Your decision

Military Veteran Status
Are you a military Veteran?

Carer Status
Do you care for someone?

Blood Pressure Readings

Blood Pressure

	Day 1	Day2	Day3	Day 4	Day 5
Systolic (Top Number)
Diastolic (Bottom Number)

Height & Weight
BMI Calculator

Smoking Status
Do you smoke?

Complete - Compulsory
Please sign to confirm that the information provided above is true. Signature must be that of the patient themselves, who in signing has consent for their medical records to be updated.
Signature *

Clear
Hidden Answer Section

For practice use only
Gender Identity
Ethnicity
Orientation
Opt Out Coding
Veteran Status
Carer Status
BP Systolic
BP Diastolic
BMI via KLINIK
Smoking Status
Should be Empty: