Veteran Status Form

Please select the practice location most relevant to this Online Form submission:

Veteran Status Form

Are You A Veteran?

Forename

Surname

Date Of Birth

Phone

Address

Postcode

Do you have other household members?

If you have other people in your household they may be entitled to benefits too. Please let us know their name and details below so that we may register them as such.

Name, Date of Birth, Phone and Email for each family member

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 Springhill Medical Centre • Phil Collins Way, Old Arley, Coventry, CV7 8FD.

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.