SMS & Email Consent Form - Wycliffe

Last Updated: 15/10/2019

Your Details

Name *

Date of Birth *

Contact Number *

Consenting to EMAILS

I consent to Wycliffe Surgery sending me emails related to my medical care and other aspects of health *

I consent to email correspondence

No, I do not

Please enter the email you would like us to use if applicable

Consenting to SMS and Texts

I consent to Wycliffe Surgery sending me sms messages related to my medical care and other aspects of health *

I consent to SMS correspondence

No, I do not

Please enter the mobile number you would like us to use if applicable

DATA COLLECTION AND STORAGE

This form collects your name and date of birth and other personal information. This is to confirm that you are registered with Wycliffe Surgery and to allow the practice team to contact you. Please read our privacy policy to discover how we protect and manage your submitted data.

To submit this form now, please complete the following *

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

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SMS & Email Consent Form - Wycliffe

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