Communication Consent Form

First Name *

Last Name *

Email *

Enter Email

Confirm Email *

Confirm Email

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Mobile Phone Number *

Email Message

We need to have your consent to begin communicating with you by email. Please tick to accept in the boxes below.

EMAIL COMMUNICATION
Some of our doctors would like to use email for patients consultations. If you would be happy to participate in email consultations please enter your email above. Please be aware that there may be confidential information included in an email and you must be happy for this to be sent to the email address you provide.
I agree to advise the practice if my email address changes or if this is no longer used.
Email messages are generated using secure facility and do not share your contact details with external organisations.

I wish to use the Email message service *

Yes

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

I agree to advise the practice if my email address changes.

I understand that email messages are generated using a secure facility and do not share your contact details with external organisations.

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

Text Message

We need to have your consent to begin communicating with you by text. Please tick to accept in the boxes below.

TEXT MESSAGE COMMUNICATION
If you are happy for us to text you for the purposes of health promotion, appointment reminders, normal blood tests and general health related information about you, please read this section carefully.

The text message service is an additional service and may not happen on all occasions and that the responsibility of attending appointments, cancelling appointments and obtaining test results are the patients responsibility. You can cancel the text message service at anytime. The text messages are generated using a secure facility however they are transmitted over a public network onto a personal telephone and as such may not be secure. The practice will not transmit any information which would enable an individual to be identified.

I wish to use the text message service *

Yes

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.

Video Consultations

We need to have your consent to begin communicating with you by text or email. Please tick to accept in the boxes below.

VIDEO CONSULTATIONS
The practice has recently started using video consultations as a way of contacting patients. The service is free and you can speak to the clinician safely, securely and from the comfort of your home. For this you would need a device with a camera (smart phone, tablet, laptop or computer). We would need to send you a text message or email with a link for the video call, for this you would have needed to consent to receive text messsage or email for this link to be sent to you.

Would you be happy to use video consulations *

Yes

I consent to the practice contacting me via video consultations

I understand that for this service I would need a device with a webcam on it like a smart phone, tablet or computer.

I have consented to text message and/or email for a video link to be sent to be.

I understand I can cancel the video consulation 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.

Signature

Clear

I consent to the practice collecting and storing my data from this form.

Communication Consent Form

Email Message

Text Message

Video Consultations

Privacy Policy

Health A-Z

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Medicines Guide

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Willow Green Surgery

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