Communication consent

Patient Name:

Date of Birth:

Email Address:

Mobile Phone Number:

I wish to make use of the email and/or text communication service(s) offered by the surgery:

I understand how these communication systems work and the type of communication that can take place via email and/or text messages.

I have read and will comply with the requirements outlined in the patient information leaflet.

I would like a verbal explanation of these communication methods.

I would like to communicate with the surgery by: (please tick all that apply)

Email – I understand that internet email is not a secure medium. I understand that there is a possibility that my emails and the responses could be intercepted and read by someone else. I understand that if I require urgent clinical advice or attention I should contact my GP.

Non-Detailed Text Messages – I understand that non-detailed text messages will simply ask me to contact the surgery to retrieve a message.

Detailed Text Messages – I understand that detailed text messages may contain clinical, appointment or other personal information.

Date

Tell us whether you accept cookies