Email and text message consent

Full Name: *

Date of Birth: *

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

Phone Number:

Email Address: *

Any responses we send will go to this email address.

NHS Number (if known):

Your Consent

We need your consent to begin communicating with you by text or email: *

I consent to the practice contacting me by text messages or email for the purposes of health promotion

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 is mine

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 Larkside Practice, and to allow the practice team to contact you and also to update your medical records held by Larkside Practice and our partners in the NHS.

Please read our Privacy Policy to discover how we protect and manage your submitted data.

Consent *

I consent to the practice collecting and storing my personal information from this form

Signature: *

Enter full name

Date:

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Your Consent

Privacy Policy