Drs McMaster, Moore & Brooksbank’s Practice – CHANGE OF PATIENT’S NAME

AND/OR ADDRESS DETAILS

Scotland
Deed Poll does not exist under Scots law. Scots law requires only that no one can change his or her name with the
intent to defraud. To change the surname of a person under age 16, the permission of all those with parental
responsibility is required.

While merely informing others of the new name is enough for it to take legal effect, those whose births are registered in
Scotland or have been legally adopted there can optionally apply to the Registrar General for Scotland to have their
birth certificate amended to show the new name and have the respective register updated.
SAILDETSOUEVIPR

Surname Title

Forename Middle Name

Previous Surname Date of Birth

Address

Postcode

NEW Surname Title

NEW DETAILS

NEW Forename Date of Birth

NEW Address

Postcode
Telephone Number:
Signature

Date
Print Name
If Child Under 16 Please State Relationship to Patient:

Name Changed By Deed Poll YES NO

Name Changed With the Registrar General for Scotland YES NO