Communication Consent Form

To enable us to continue contact with you, please complete our communication consent form. We will update your records with your preferred contact method.

If you are human, leave this field blank.

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 Haydock Medical Centre.

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 Haydock Medical Centre 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

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