Communications Consent Form

We want to keep being able to send you Practice communications by email and text message, but first, we need your permission.

Please provide your details and consent by completing and submitting this form.

Why should I consent to received text messages and emails from the Barcellos Family Practice?

Not only is it a quick and low-cost way for the NHS to contact patients, it saves a patients time waiting on the phone to get through to the Practice or having to visit the surgery.

Your Details

Name *

Date of Birth (DD/MM/YYYY) *

Mobile Number *

Email Address *

Your Consent

We need to have your consent to begin communicating with you by text or email.

Please confirm your consent by ticking to accept the options below. *

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.

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA.

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

The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.

I confirm the information I’ve given is correct and I understand how it will be used

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Page last reviewed: 12 October 2024
Page created: 14 October 2026