SMS Text Messaging and Email Consent Form

Last Updated: 22/09/2020

Your Details

Full name *

Date of Birth *

NHS Number (if known)

Mobile Number *

Email Address *

In the event of a parent/guardian signing for a child of 12 years and under, please state your relationship

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

I explicitly consent to The Beacon Health Group contacting me via SMS text messaging and email

I decline and do not wish to be contacted by this method

I understand that it is my responsibility to advise The Beacon Health Group if my mobile number changes or if it is no longer inmy possession. Should you wish to withdraw consent please give at least 5 working days’ notice in writing quoting above mobile number/email address.

Signature *

Date *

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SMS Text Messaging and Email Consent Form

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