SMS/Email consent form

As part of your medical care we would like to share with the Out of Hours Service?
Do you consent to the practice sharing your medical information with the Emergency services and hospital services?
Do we have your current contact information?
Please let us know your current email address and mobile number.
We use mobile numbers to send text reminders for appointments.
We also send relevant information to email addresses and mobile numbers.
Consent can be withdrawn or given at any time

Please write yes or no to consent to us sharing your information with emergency services and hospital services
Name
Mobile Number
email
Date of Birth
     

   Please complete below   
Please write yes to consent to contact by text
Please write yes to consent to contact by email
Please write no to withdraw contact by text
Please write no to withdraw contact by email

CONFIDENTIALITY TERMS AND CONDITIONS
The internet is not secure, and the transmission of data to request
medication is entirely at the patients own risk . The practice accepts no
responsibility for breaches in confidentiality resulting from patients transmissions.

By clicking submit you agree to the terms and conditions of using this service.