Communication Consent Form Communication Consent First Name * Last Name * Email * Date of birth * Please use format day/month/year e.g. 12/05/1979 Mobile Phone Number * Declaration I consent to the practice contacting me by text message and/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. I can cancel the text message facility at any time. 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, however the practice will not transmit any information which would enable an individual patient to be identified. Terms & Conditions By using the forms contained here you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that because of the nature of the Internet we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of communicating with the practice. Your data is not retained by this website server but are used to update your records with the practice. Send If you are human, leave this field blank.