Communication Consent Form

We would like to keep be able to send you practice communications by email and telephone, but first we need your permission. Please provide your details and consent below.

Communication Consent

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

Mobile Phone Number *

Your Consent

We need to have your consent to begin communicating with you by telephone or email.

I consent to the practice contacting me by telephone or email for the purposes of health promotion, practice news and for appointment reminders.

Privacy Policy

This form collects your name, date of birth, email and other personal information. 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.

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Your Consent

Privacy Policy

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