Communication Consent Form

We would like to keep be able to send you Practice communications by email and text message, but first we need your permission. Please provide your details and consent below. Do not use this form if you are not the patient. If you are a Carer or Patient’s representative please contact the Practice for advice.

Communication Consent

First Name *

Last Name *

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 text or email. Please tick to accept in the boxes below.

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

I acknowledge that appointment reminders by text are an additional service and that they may not be sent on all occasions but that the responsibility for attending appointments or cancelling them still rests with me.

Text messages are generated using a secure facility but I understand that they are transmitted over a public network onto a personal telephone and as such may not be secure.

I understand I can cancel the text message facility at any time.

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.

Patient’s Signature

Clear

If you are human, leave this field blank.

Communication Consent Form

Your Consent

Privacy Policy

Parkgate Surgery

County Road Surgery

Contact Us

Limited services Monday 6th January due to power cuts in the area of St Helens Road.

Communication Consent Form

Your Consent

Privacy Policy

Parkgate Surgery

County Road Surgery

Contact Us