Consent for Text Messages and Emails

Patient Details

Please use date format DD/MM/YYYY
In the first instance, this will be used for responses to this request and, if consented, any subsequent contact
This will be used for telephone calls
This will be used for telephone calls and text messages (SMS)

How would you prefer the surgery to contact you?

Please ensure that you have filled in the correct phone number(s) and email address above.

Text Messages

The surgery can contact you via text message (SMS) regarding lots of different things such as test results, health issues and advice regarding further treatment.

Do you give consent to the surgery contacting you via text message? *
Do you give consent to receive your test results from the surgery via text message?
Do you give consent to receive clinical information from the surgery such as advice or a response to a question or e-consult query via text message?
Do you give consent for the surgery to contact you with a generic text message which is information only – a message will be sent for you to contact the surgery but no other information included in this message?

Email Messages

The surgery can contact you via email regarding lots of different things such as test results, health issues and advice regarding further treatment.

Do you give consent to the surgery contacting you via email? *
Do you give consent to receive your test results from the surgery via email?
Do you give consent to receive clinical information from the surgery such as advice or a response to a question or e-consult query via email?

Consent for a Third Party to Receive Messages on your Behalf

If you wish to, you can nominate for another person such as a family member or carer to receive messages on your behalf.

Please ask reception for a Patient Authorisation
form.