Text Messaging and Email Consent

The practice is using a SMS text and email service.

This service may be used to send text and email reminders to patients regarding upcoming or cancelled appointments, requests to attend for repeat tests if your GP deems appropriate, speak to the doctor / nurse or book an appointment. We may also use this service to contact patients about health promotion.

We always strive to maintain confidentiality of your information and will continue to do so while using this system. To help us do this, it is important that you let us know if you change your mobile number or email address in the future.

If you give consent for us to communicate with you by mobile text messaging and / or email as outlined above please fill in the form below. If you decide you no longer wish to receive messages through this service please inform us.

By giving us your home phone/mobile number and email address on any of our online forms, we assume consent to reply via telephone call/text/email.

Text Messaging and Email Consent

This service is available for patients aged 16 and over.

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Mobile Number:

Tick the box to confirm that this is your mobile number and does not belong to another person.

Landline Number:

Email Address: *

By giving us your email address on this online form, we assume consent to reply to this form via email when necessary. If you prefer not to receive email, please contact the surgery by telephone.

Do you have any communication/information needs relating to disability, impairment or sensory loss?

Yes

No

Please be specific:

I confirm that I have read and understood the information above and consent to receiving mobile and / or email messages as indicated above from the Quarter Jack Surgery.

Signature: *

Date: