Text, Email Message Service & Answer Phone Patient Consent Form

Last Updated: 09/06/2020

Text, Email Message Service & Answer Phone Patient Consent Form

Emails and text messages are generated using a secure facility, but because they are transmitted over a public network they may not be secure. Your contact details will be used solely in relation to healthcare services offered by the practice, and you can choose to opt out of the services at any time by contacting the practice. Wallingbrook Health Group will not transmit any information which would enable an individual patient to be identified unless the below consent form has been completed and signed.

Name *

Date of Birth *

Home Telephone Number

Mobile Number *

Email Address *

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU. 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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Text, Email Message Service & Answer Phone Patient Consent Form

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